Provider First Line Business Practice Location Address:
1025 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
SUITE LL15
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-1593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-753-1739
Provider Business Practice Location Address Fax Number:
574-753-1549
Provider Enumeration Date:
09/26/2008