Provider First Line Business Practice Location Address:
4402 CHURCHMAN AVENUE SUITE 306 MEDICAL PLAZA 1
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:
40215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-852-0132
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2026