Provider First Line Business Practice Location Address:
2105 CRUMS LANE
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:
40216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-589-8950
Provider Business Practice Location Address Fax Number:
502-499-3690
Provider Enumeration Date:
09/25/2006