Provider First Line Business Practice Location Address:
2121 25TH STREET
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47201-3214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-379-9561
Provider Business Practice Location Address Fax Number:
812-372-8157
Provider Enumeration Date:
12/05/2006