Provider First Line Business Practice Location Address:
801 BARRET AVE
Provider Second Line Business Practice Location Address:
STE 112
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-200-8259
Provider Business Practice Location Address Fax Number:
502-584-8379
Provider Enumeration Date:
12/06/2005