Provider First Line Business Practice Location Address:
2203 CAROLINA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40205-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-724-4355
Provider Business Practice Location Address Fax Number:
502-384-4011
Provider Enumeration Date:
12/30/2008