Provider First Line Business Practice Location Address:
1101 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-1528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-753-1502
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2006