Provider First Line Business Practice Location Address:
1017 W MARKET 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:
40202-2630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-357-1986
Provider Business Practice Location Address Fax Number:
502-587-9565
Provider Enumeration Date:
02/01/2017