Provider First Line Business Practice Location Address: 
321 MITCHELL AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BATESVILLE
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
47006
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
812-934-6624
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/13/2005