Provider First Line Business Practice Location Address:
4125 S 3RD 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:
40214-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-205-1299
Provider Business Practice Location Address Fax Number:
502-362-1201
Provider Enumeration Date:
01/18/2025