Provider First Line Business Practice Location Address:
12802 EAST US HIGHWAY 50
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOOGOOTEE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47553-5210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-295-2101
Provider Business Practice Location Address Fax Number:
812-295-2102
Provider Enumeration Date:
02/16/2007