Provider First Line Business Practice Location Address: 
125 LAKESHORE DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LEBANON
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46052-3100
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
765-680-0071
    Provider Business Practice Location Address Fax Number: 
765-680-0468
    Provider Enumeration Date: 
06/03/2013