Provider First Line Business Practice Location Address:
1549 SOUTH COURT STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46307-4809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-662-0131
Provider Business Practice Location Address Fax Number:
219-662-3962
Provider Enumeration Date:
10/02/2006