Provider First Line Business Practice Location Address: 
8 NORTH MORGEN BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VALPARAISO
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46383
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-464-9495
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/14/2006