Provider First Line Business Practice Location Address:
417 NORTH ST
Provider Second Line Business Practice Location Address:
STE 2A
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-2744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-727-0819
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2005