Provider First Line Business Practice Location Address:
279 N GARDNER ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47170-1322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-752-5106
Provider Business Practice Location Address Fax Number:
812-752-5132
Provider Enumeration Date:
10/11/2005