Provider First Line Business Practice Location Address:
4922 POPLAR LEVEL RD
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:
40219-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-434-4466
Provider Business Practice Location Address Fax Number:
502-434-4467
Provider Enumeration Date:
04/19/2021