Provider First Line Business Practice Location Address:
708 MAGAZINE 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:
40203-2043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
150-258-9860
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2022