Provider First Line Business Practice Location Address:
720 W BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-2240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-593-5502
Provider Business Practice Location Address Fax Number:
502-583-1330
Provider Enumeration Date:
02/15/2007