Provider First Line Business Practice Location Address:
1347 S 3RD 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:
40208-3306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-550-0576
Provider Business Practice Location Address Fax Number:
502-635-2457
Provider Enumeration Date:
02/19/2017