Provider First Line Business Practice Location Address: 
250 N MAIN ST STE 11F
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CROWN POINT
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46307-3279
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-669-9476
    Provider Business Practice Location Address Fax Number: 
219-280-3268
    Provider Enumeration Date: 
06/22/2010