Provider First Line Business Practice Location Address:
5120 DIXIE HWY STE 102
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:
40216-1775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-448-0931
Provider Business Practice Location Address Fax Number:
502-448-0918
Provider Enumeration Date:
08/16/2019