Provider First Line Business Practice Location Address:
1832 PRAIRIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46613-1400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-287-5712
Provider Business Practice Location Address Fax Number:
574-289-2763
Provider Enumeration Date:
09/23/2005