Provider First Line Business Practice Location Address: 
9135 N MERIDIAN ST
    Provider Second Line Business Practice Location Address: 
SUITE A-6
    Provider Business Practice Location Address City Name: 
INDIANAPOLIS
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46260-1878
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
317-581-1433
    Provider Business Practice Location Address Fax Number: 
317-581-1471
    Provider Enumeration Date: 
07/25/2011