Provider First Line Business Practice Location Address:
8485 W US HIGHWAY 20
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
MICHIGAN CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46360-7628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-861-0555
Provider Business Practice Location Address Fax Number:
219-861-0556
Provider Enumeration Date:
09/27/2005