Provider First Line Business Practice Location Address:
806 ULRICH 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:
40219-1846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-697-0057
Provider Business Practice Location Address Fax Number:
423-648-9366
Provider Enumeration Date:
08/25/2011