Provider First Line Business Practice Location Address: 
98 ELM ST STE 400
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAWRENCEBURG
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
47025-2047
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
812-496-8775
    Provider Business Practice Location Address Fax Number: 
812-537-5710
    Provider Enumeration Date: 
09/06/2011