Provider First Line Business Practice Location Address:
2219 HOLIDAY MANOR CTR
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:
40222-6463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-394-9483
Provider Business Practice Location Address Fax Number:
502-426-0281
Provider Enumeration Date:
06/18/2011