Provider First Line Business Practice Location Address:
7118 SOUTHSIDE DR
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:
40214-3660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-364-8054
Provider Business Practice Location Address Fax Number:
502-363-9403
Provider Enumeration Date:
05/26/2008