Provider First Line Business Practice Location Address: 
401 E CHESTNUT ST UNIT 110
    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: 
40202
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
502-852-6446
    Provider Business Practice Location Address Fax Number: 
502-852-6649
    Provider Enumeration Date: 
08/08/2012