Provider First Line Business Practice Location Address:
1616 SMITH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-1264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-722-3650
Provider Business Practice Location Address Fax Number:
574-722-5741
Provider Enumeration Date:
07/21/2005