Provider First Line Business Practice Location Address:
12464 LA GRANGE RD
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:
40245-1901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-205-2090
Provider Business Practice Location Address Fax Number:
502-205-2091
Provider Enumeration Date:
07/05/2005