Provider First Line Business Practice Location Address: 
3229 BROADWAY AVE.
    Provider Second Line Business Practice Location Address: 
SUITE 205
    Provider Business Practice Location Address City Name: 
GARY
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46409-2512
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-531-3500
    Provider Business Practice Location Address Fax Number: 
219-427-0434
    Provider Enumeration Date: 
05/08/2015