Provider First Line Business Practice Location Address:
279 N GARDNER ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47170-1322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-288-8566
Provider Business Practice Location Address Fax Number:
812-284-2326
Provider Enumeration Date:
09/29/2006