Provider First Line Business Practice Location Address:
719 SPENCER 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:
46947-3583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-739-5048
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2025