Provider First Line Business Practice Location Address:
2120 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:
40206-2012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-491-1307
Provider Business Practice Location Address Fax Number:
812-492-6498
Provider Enumeration Date:
11/06/2020