Provider First Line Business Practice Location Address:
550 S JACKSON 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:
40202-1622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-813-6724
Provider Business Practice Location Address Fax Number:
502-217-5056
Provider Enumeration Date:
08/23/2011