Provider First Line Business Practice Location Address:
12418 LA GRANGE RD STE 115
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:
40245-2905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-890-6009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2019