Provider First Line Business Practice Location Address: 
7250 ARTHUR BLVD
    Provider Second Line Business Practice Location Address: 
SUITE # 180
    Provider Business Practice Location Address City Name: 
MERRILLVILLE
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46410-3766
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
866-334-7777
    Provider Business Practice Location Address Fax Number: 
317-569-1403
    Provider Enumeration Date: 
08/29/2013