Provider First Line Business Practice Location Address:
130 FAIRFAX AVE
Provider Second Line Business Practice Location Address:
LOWER LEVEL, 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:
40207-4939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-759-2517
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2007