Provider First Line Business Practice Location Address:
1815 S 22ND ST
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:
40210-2149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-224-5690
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/24/2025