Provider First Line Business Practice Location Address:
2821 WEST BROADWAY
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:
40211-1218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-774-8516
Provider Business Practice Location Address Fax Number:
502-774-8518
Provider Enumeration Date:
08/22/2013