Provider First Line Business Practice Location Address:
1300 STATE STREET
Provider Second Line Business Practice Location Address:
SUITE 1B
Provider Business Practice Location Address City Name:
LA PORTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46350-3134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-326-5700
Provider Business Practice Location Address Fax Number:
219-326-8131
Provider Enumeration Date:
08/17/2006