Provider First Line Business Practice Location Address:
505 WALLACE 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:
40207-3768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-937-5073
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2024