Provider First Line Business Practice Location Address:
1015 DORSEY LANE
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:
40223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-819-3036
Provider Business Practice Location Address Fax Number:
502-254-7906
Provider Enumeration Date:
01/30/2014