Provider First Line Business Practice Location Address:
781 E NORTH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENDALLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46755-1225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-347-3458
Provider Business Practice Location Address Fax Number:
260-347-4425
Provider Enumeration Date:
06/17/2005