Provider First Line Business Practice Location Address:
100 E 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSONVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47130-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-288-7179
Provider Business Practice Location Address Fax Number:
812-282-0203
Provider Enumeration Date:
09/25/2006