Provider First Line Business Practice Location Address:
11540 BLANKENBAKER ACCESS DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40299-6428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-297-8223
Provider Business Practice Location Address Fax Number:
800-845-8650
Provider Enumeration Date:
11/21/2005