Provider First Line Business Practice Location Address:
4500 CHURCHMAN AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40215-1188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-361-1389
Provider Business Practice Location Address Fax Number:
502-368-1221
Provider Enumeration Date:
05/17/2011