Provider First Line Business Practice Location Address:
4801 OUTER LOOP
Provider Second Line Business Practice Location Address:
C524
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40219-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-966-8638
Provider Business Practice Location Address Fax Number:
502-964-7309
Provider Enumeration Date:
07/31/2006