Provider First Line Business Practice Location Address:
2512 PORTLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-501-3788
Provider Business Practice Location Address Fax Number:
502-999-9910
Provider Enumeration Date:
12/26/2024