Provider First Line Business Practice Location Address:
3113 S 4TH 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:
40214-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-375-3800
Provider Business Practice Location Address Fax Number:
502-375-0085
Provider Enumeration Date:
10/12/2006