Provider First Line Business Practice Location Address: 
1112 US HIGHWAY 41
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SCHERERVILLE
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46375-1361
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-613-0332
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/27/2011