Provider First Line Business Practice Location Address:
1027 BAXTER AVE
Provider Second Line Business Practice Location Address:
UNIT ONE
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40204-1605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-587-0711
Provider Business Practice Location Address Fax Number:
502-587-0144
Provider Enumeration Date:
02/14/2007