Provider First Line Business Practice Location Address:
2418 W MARKET 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:
40212-1539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-772-0704
Provider Business Practice Location Address Fax Number:
502-772-9587
Provider Enumeration Date:
05/22/2007