Provider First Line Business Practice Location Address:
3999 DUTCHMANS LN
Provider Second Line Business Practice Location Address:
SUBURBAN MEDICAL PLAZA I STE 2G
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-893-0491
Provider Business Practice Location Address Fax Number:
502-895-7360
Provider Enumeration Date:
07/08/2005