Provider First Line Business Practice Location Address: 
2440 WILSON ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GARY
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46404-3249
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-290-7252
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/03/2023