Provider First Line Business Practice Location Address:
3975 7TH STREET RD
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:
40216-4103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-825-0075
Provider Business Practice Location Address Fax Number:
859-878-2038
Provider Enumeration Date:
12/18/2018