Provider First Line Business Practice Location Address:
5141 DIXIE HWY
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40216-1765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-448-7988
Provider Business Practice Location Address Fax Number:
502-447-9326
Provider Enumeration Date:
10/19/2005