Provider First Line Business Practice Location Address:
5135 DIXIE HWY
Provider Second Line Business Practice Location Address:
SUITE 25
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40216-1771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-449-5046
Provider Business Practice Location Address Fax Number:
502-449-5048
Provider Enumeration Date:
09/15/2010