Provider First Line Business Practice Location Address:
1828 E BROADWAY
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-753-4455
Provider Business Practice Location Address Fax Number:
574-722-5425
Provider Enumeration Date:
02/07/2007