Provider First Line Business Practice Location Address:
1433 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENDALLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46755-2104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-347-3612
Provider Business Practice Location Address Fax Number:
260-349-0336
Provider Enumeration Date:
07/02/2006