Provider First Line Business Practice Location Address:
3432 ILLINOIS 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:
40213-1018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-435-9226
Provider Business Practice Location Address Fax Number:
502-634-1170
Provider Enumeration Date:
05/04/2010