Provider First Line Business Practice Location Address:
4601 S 6TH ST
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:
40214-1405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-791-6090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2025