Provider First Line Business Practice Location Address:
530 SOUTH JACKSON ST
Provider Second Line Business Practice Location Address:
SUITE #C1H17
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-852-6599
Provider Business Practice Location Address Fax Number:
502-852-1606
Provider Enumeration Date:
03/29/2006