Provider First Line Business Practice Location Address:
4402 CHURCHMAN AVENUE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-361-5253
Provider Business Practice Location Address Fax Number:
502-361-9038
Provider Enumeration Date:
08/01/2005