Provider First Line Business Practice Location Address:
2301 E MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-2037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-735-3815
Provider Business Practice Location Address Fax Number:
574-739-0824
Provider Enumeration Date:
11/10/2011