Provider First Line Business Practice Location Address: 
730 45TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MUNSTER
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46321-2818
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-924-3300
    Provider Business Practice Location Address Fax Number: 
219-934-2658
    Provider Enumeration Date: 
08/07/2006