Provider First Line Business Practice Location Address:
301 W HOMER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MICHIGAN CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46360-4358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-872-7464
Provider Business Practice Location Address Fax Number:
219-877-1066
Provider Enumeration Date:
08/12/2005