Provider First Line Business Practice Location Address:
12546 E US HIGHWAY 50
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOOGOOTEE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47553-5220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-295-5095
Provider Business Practice Location Address Fax Number:
812-295-9403
Provider Enumeration Date:
04/18/2006