Provider First Line Business Practice Location Address:
1115 W MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-3338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-735-0082
Provider Business Practice Location Address Fax Number:
574-753-3193
Provider Enumeration Date:
11/13/2007