Provider First Line Business Practice Location Address:
201 E JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE 201 B
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-1246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-569-2058
Provider Business Practice Location Address Fax Number:
502-569-1065
Provider Enumeration Date:
05/27/2014