Provider First Line Business Practice Location Address:
744 E MADISON ST
Provider Second Line Business Practice Location Address:
APT C
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-1686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-298-8041
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2007