Provider First Line Business Practice Location Address:
2417 VINEDALE AVE
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:
40220-3632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-819-5476
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2025