Provider First Line Business Practice Location Address:
4007 VERMONT AVE
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:
40211-3020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-269-6837
Provider Business Practice Location Address Fax Number:
463-242-5584
Provider Enumeration Date:
03/19/2026