Provider First Line Business Practice Location Address:
1426 S 28TH 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:
40211-1729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-500-9443
Provider Business Practice Location Address Fax Number:
502-632-1432
Provider Enumeration Date:
07/14/2020