Provider First Line Business Practice Location Address:
1122 PAYNE ST
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:
40204-2314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-259-3950
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2021