Provider First Line Business Practice Location Address:
1200 S WOODLAND AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MICHIGAN CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46360-7383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-221-6119
Provider Business Practice Location Address Fax Number:
219-979-6775
Provider Enumeration Date:
09/26/2013