Provider First Line Business Practice Location Address:
10511 LA GRANGE RD BLDG 1
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:
40223-1277
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-489-5209
Provider Business Practice Location Address Fax Number:
502-489-5213
Provider Enumeration Date:
07/31/2018