Provider First Line Business Practice Location Address:
4788 S LICK CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46160-9598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-597-5572
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2007