Provider First Line Business Practice Location Address: 
1000 COUNTY ROAD WEST LONETREE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LINTON
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
47441-0553
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
812-847-4435
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/22/2013