Provider First Line Business Practice Location Address: 
720 ESKENAZI AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
INDIANAPOLIS
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46202-5187
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
317-880-7666
    Provider Business Practice Location Address Fax Number: 
317-880-0448
    Provider Enumeration Date: 
05/12/2006