Provider First Line Business Practice Location Address:
7410 NEW LA GRANGE RD
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40222-4871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-742-0460
Provider Business Practice Location Address Fax Number:
502-742-9340
Provider Enumeration Date:
01/25/2016