Provider First Line Business Practice Location Address:
322 W WOODLAWN 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:
40214-1924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-261-9694
Provider Business Practice Location Address Fax Number:
800-811-0627
Provider Enumeration Date:
10/20/2014