Provider First Line Business Practice Location Address:
102A FAIRFAX 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:
40207-4906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-897-9560
Provider Business Practice Location Address Fax Number:
502-897-9577
Provider Enumeration Date:
05/30/2008