Provider First Line Business Practice Location Address:
3729 FIR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST CHICAGO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46312-2227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-397-1779
Provider Business Practice Location Address Fax Number:
219-397-1977
Provider Enumeration Date:
12/05/2009