Provider First Line Business Practice Location Address:
990 BAXTER 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:
40204-2064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-585-3239
Provider Business Practice Location Address Fax Number:
502-583-3162
Provider Enumeration Date:
08/26/2011