Provider First Line Business Practice Location Address:
1481 W 10TH STREET
Provider Second Line Business Practice Location Address:
AMB 11 RICHARD L ROUDELOUSH VA MEDICAL CENTER
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
46202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-988-2205
Provider Business Practice Location Address Fax Number:
317-988-4706
Provider Enumeration Date:
09/14/2006