Provider First Line Business Practice Location Address:
1425 STORY AVE
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:
40206-1735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-584-1369
Provider Business Practice Location Address Fax Number:
502-585-3989
Provider Enumeration Date:
12/15/2006