Provider First Line Business Practice Location Address:
9720 PARK PLAZA AVE UNIT 104
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:
40241-2289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-895-8218
Provider Business Practice Location Address Fax Number:
502-895-8219
Provider Enumeration Date:
09/26/2014