Provider First Line Business Practice Location Address:
1642C W MCCLAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47170-1161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-752-4185
Provider Business Practice Location Address Fax Number:
812-752-6425
Provider Enumeration Date:
07/05/2005