Provider First Line Business Practice Location Address:
4912 US HIGHWAY 42 STE 104
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:
40222-6357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-429-8640
Provider Business Practice Location Address Fax Number:
502-426-2283
Provider Enumeration Date:
05/14/2021