Provider First Line Business Practice Location Address: 
6610 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: 
40291-3045
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
502-233-8048
    Provider Business Practice Location Address Fax Number: 
502-373-1288
    Provider Enumeration Date: 
07/22/2014