Provider First Line Business Practice Location Address:
1120 SPEAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-732-0701
Provider Business Practice Location Address Fax Number:
574-732-0428
Provider Enumeration Date:
05/16/2011