Provider First Line Business Practice Location Address:
15100 N BASELINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDINBURGH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46124-9004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-343-9120
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2025