Provider First Line Business Practice Location Address:
2406 W BROADWAY
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:
40211-1008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-775-1711
Provider Business Practice Location Address Fax Number:
502-443-0369
Provider Enumeration Date:
06/25/2008