Provider First Line Business Practice Location Address: 
337 HARMS ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NORTH VERNON
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
47265-2309
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
812-346-1440
    Provider Business Practice Location Address Fax Number: 
812-346-1440
    Provider Enumeration Date: 
10/29/2006