Provider First Line Business Practice Location Address:
720 W CHICAGO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST CHICAGO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46312-3222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-397-6208
Provider Business Practice Location Address Fax Number:
219-378-1330
Provider Enumeration Date:
09/09/2011