Provider First Line Business Practice Location Address:
1219 COOPER 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:
40219-5002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-235-5479
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2024