Provider First Line Business Practice Location Address:
CORNER OF MAIN ST. & MORTON ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHIPSHEWANA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46565-0155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-768-4882
Provider Business Practice Location Address Fax Number:
260-768-7832
Provider Enumeration Date:
12/16/2005