Provider First Line Business Practice Location Address:
1015 E 149TH ST
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:
46312-3771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-397-5117
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2008