Provider First Line Business Practice Location Address:
636 E ORMSBY 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:
40203-2623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-383-9771
Provider Business Practice Location Address Fax Number:
888-425-0446
Provider Enumeration Date:
02/16/2021