Provider First Line Business Practice Location Address:
9801 PRAIRIE AVE
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
HIGHLAND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46322-3633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-922-9595
Provider Business Practice Location Address Fax Number:
219-922-3821
Provider Enumeration Date:
05/23/2005