Provider First Line Business Practice Location Address:
1009 N DUPONT SQ
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:
40207-4612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-721-5220
Provider Business Practice Location Address Fax Number:
502-894-9991
Provider Enumeration Date:
01/03/2008