Provider First Line Business Practice Location Address:
5100 DIXIE HWY
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:
40216-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-447-3347
Provider Business Practice Location Address Fax Number:
502-447-3960
Provider Enumeration Date:
12/05/2020