Provider First Line Business Practice Location Address:
1436 S SHELBY 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:
40217-1107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-635-4518
Provider Business Practice Location Address Fax Number:
502-636-0597
Provider Enumeration Date:
01/13/2015