Provider First Line Business Practice Location Address: 
3171 N MERIDIAN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
INDIANAPOLIS
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46208-4784
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
317-941-5003
    Provider Business Practice Location Address Fax Number: 
317-931-5140
    Provider Enumeration Date: 
10/01/2009