Provider First Line Business Practice Location Address:
1311 E BRECKINRIDGE 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:
40204-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-416-4629
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/06/2017