Provider First Line Business Practice Location Address:
1313 W CHICAGO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST CHICAGO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46312-3316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-397-1196
Provider Business Practice Location Address Fax Number:
219-392-4958
Provider Enumeration Date:
10/27/2009