Provider First Line Business Practice Location Address:
1201 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
STE 330
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-1580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-753-4151
Provider Business Practice Location Address Fax Number:
574-722-1560
Provider Enumeration Date:
11/30/2006