Provider First Line Business Practice Location Address:
631 S 28TH 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:
40211-1369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-776-3066
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2007