Provider First Line Business Practice Location Address: 
3101 POPLAR LEVEL RD STE 101
    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: 
40213-1076
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
502-636-7444
    Provider Business Practice Location Address Fax Number: 
502-636-7112
    Provider Enumeration Date: 
04/12/2018