Provider First Line Business Practice Location Address:
506 MALCOLM 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:
40223-2535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-271-8486
Provider Business Practice Location Address Fax Number:
502-271-8486
Provider Enumeration Date:
08/27/2025