Provider First Line Business Practice Location Address:
315 E BROADWAY STE 185-C
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:
40202-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-629-5455
Provider Business Practice Location Address Fax Number:
502-629-4151
Provider Enumeration Date:
07/30/2007