Provider First Line Business Practice Location Address: 
3819 KENTUCKY AVE
    Provider Second Line Business Practice Location Address: 
3819 KENTUCKY AVE
    Provider Business Practice Location Address City Name: 
INDIANAPOLIS
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46221-2709
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
317-856-0880
    Provider Business Practice Location Address Fax Number: 
317-856-0886
    Provider Enumeration Date: 
02/07/2007