Provider First Line Business Practice Location Address:
5120 DIXIE HWY
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40216-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-449-0449
Provider Business Practice Location Address Fax Number:
502-449-3277
Provider Enumeration Date:
08/25/2006