Provider First Line Business Practice Location Address:
1203 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PORTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46350-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-326-2397
Provider Business Practice Location Address Fax Number:
219-326-2697
Provider Enumeration Date:
06/28/2007