Provider First Line Business Practice Location Address: 
124 W VOTAW ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PORTLAND
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
47371-1143
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
260-726-2049
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/10/2014