Provider First Line Business Practice Location Address:
1105 N GRANT STREET
Provider Second Line Business Practice Location Address:
WEST LAFAYETTE JR SR HIGH SCHOOL
Provider Business Practice Location Address City Name:
WEST LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-746-0424
Provider Business Practice Location Address Fax Number:
765-746-0426
Provider Enumeration Date:
04/21/2006