Provider First Line Business Practice Location Address:
4739 S 3RD ST
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:
40214-2123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-363-2344
Provider Business Practice Location Address Fax Number:
502-367-7964
Provider Enumeration Date:
12/19/2010