Provider First Line Business Practice Location Address:
CORNER MAIN AND MORTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHIPSHEWANA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-768-4882
Provider Business Practice Location Address Fax Number:
260-768-7238
Provider Enumeration Date:
12/29/2005