Provider First Line Business Practice Location Address:
902 W. BROADWAY
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:
46947-2978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-739-0004
Provider Business Practice Location Address Fax Number:
574-739-0105
Provider Enumeration Date:
06/21/2005