Provider First Line Business Practice Location Address:
4113 BARDSTOWN RD
Provider Second Line Business Practice Location Address:
SUITE 101A
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40218-3293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-712-1749
Provider Business Practice Location Address Fax Number:
502-491-0492
Provider Enumeration Date:
12/03/2012