Provider First Line Business Practice Location Address:
4602 SOUTHERN PKWY STE 1B
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:
40214-1442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-678-3161
Provider Business Practice Location Address Fax Number:
502-678-3162
Provider Enumeration Date:
09/04/2026