Provider First Line Business Practice Location Address:
2220 PAYNE ST # 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:
40206-2872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-303-1730
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2025