Provider First Line Business Practice Location Address:
3924-26 MAIN ST.
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
EAST CHICAGO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-397-2008
Provider Business Practice Location Address Fax Number:
219-398-1339
Provider Enumeration Date:
11/21/2005