Provider First Line Business Practice Location Address:
1509 MAGAZINE ST
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:
40203-3529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-260-1277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2026