Provider First Line Business Practice Location Address: 
2239 BARDSTOWN 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: 
40205-1917
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
502-454-0414
    Provider Business Practice Location Address Fax Number: 
502-454-6262
    Provider Enumeration Date: 
01/24/2018