Provider First Line Business Practice Location Address: 
609 N 5TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAFAYETTE
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
47901-1012
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
765-742-0202
    Provider Business Practice Location Address Fax Number: 
765-742-2414
    Provider Enumeration Date: 
04/11/2007