Provider First Line Business Practice Location Address:
4917 1/2 DIXIE HWY
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-447-1799
Provider Business Practice Location Address Fax Number:
502-447-3083
Provider Enumeration Date:
08/01/2017