Provider First Line Business Practice Location Address:
1213 ELLISON 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:
40204-1951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-999-0643
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2015