Provider First Line Business Practice Location Address:
2630 PAYNE 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:
40206-2556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-202-1779
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2014