Provider First Line Business Practice Location Address:
2010 S FIRST STREET WALK
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:
40292-0003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-852-6782
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2026