Provider First Line Business Practice Location Address:
225 N CLIFTON 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:
40206-2496
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-794-3894
Provider Business Practice Location Address Fax Number:
502-794-2873
Provider Enumeration Date:
09/08/2019