Provider First Line Business Practice Location Address:
1321 S PRESTON 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:
40208-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-636-0816
Provider Business Practice Location Address Fax Number:
502-636-5256
Provider Enumeration Date:
12/06/2016