Provider First Line Business Practice Location Address: 
3480 E 83RD PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MERRILLVILLE
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46410-6547
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-663-2896
    Provider Business Practice Location Address Fax Number: 
219-794-1077
    Provider Enumeration Date: 
10/20/2011