Provider First Line Business Practice Location Address:
2490 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE STATION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46405-2122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-763-8112
Provider Business Practice Location Address Fax Number:
219-962-1808
Provider Enumeration Date:
11/17/2008