Provider First Line Business Practice Location Address: 
3740 EDISON LAKES PKWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MISHAWAKA
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46545-3448
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
574-252-4150
    Provider Business Practice Location Address Fax Number: 
574-252-4159
    Provider Enumeration Date: 
07/29/2016