Provider First Line Business Practice Location Address:
120 S 22ND 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:
40212-1555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-242-9733
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2025