Provider First Line Business Practice Location Address:
105A CRESCENT 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:
40206-1525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-893-4011
Provider Business Practice Location Address Fax Number:
502-893-8711
Provider Enumeration Date:
10/05/2007