Provider First Line Business Practice Location Address: 
1415 FLAXMILL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HUNTINGTON
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46750-8806
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
260-359-1250
    Provider Business Practice Location Address Fax Number: 
260-359-1251
    Provider Enumeration Date: 
10/06/2006