Provider First Line Business Practice Location Address:
1907 BARDSTOWN RD
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:
40205-1525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-483-3271
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2025