Provider First Line Business Practice Location Address:
4036 LAURELWOOD 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:
40220-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-270-8288
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2025