Provider First Line Business Practice Location Address:
4013 OLD OUTERLOOP
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:
40219-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-966-5469
Provider Business Practice Location Address Fax Number:
502-966-5114
Provider Enumeration Date:
01/22/2007