Provider First Line Business Practice Location Address:
406 BLANKENBAKER PKWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40243-1881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-245-5101
Provider Business Practice Location Address Fax Number:
502-245-7602
Provider Enumeration Date:
09/05/2007