Provider First Line Business Practice Location Address:
1330 N ILLINOIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-2321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-872-7336
Provider Business Practice Location Address Fax Number:
419-872-7460
Provider Enumeration Date:
10/29/2026