Provider First Line Business Practice Location Address:
2133 W MARKET 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:
40212-1532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
23-845-8075
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2015