Provider First Line Business Practice Location Address:
1330 ELLISON AVE
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:
40204-1657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-694-9488
Provider Business Practice Location Address Fax Number:
502-276-0926
Provider Enumeration Date:
11/01/2024