Provider First Line Business Practice Location Address:
3809-B POPLAR LEVEL RD
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:
40213-1429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-459-4273
Provider Business Practice Location Address Fax Number:
502-459-4343
Provider Enumeration Date:
08/30/2006