Provider First Line Business Practice Location Address:
1301 CLEAR SPRING TRACE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40223-3855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-326-3673
Provider Business Practice Location Address Fax Number:
502-326-3674
Provider Enumeration Date:
10/31/2007