Provider First Line Business Practice Location Address:
4415 E. MARKET STREET
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:
46947-2356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-753-4871
Provider Business Practice Location Address Fax Number:
574-753-4871
Provider Enumeration Date:
12/22/2011