Provider First Line Business Practice Location Address:
550 S JACKSON ST # A3R40
Provider Second Line Business Practice Location Address:
AMBULATORY CARE BUILDING
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-1622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-852-5841
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2010