Provider First Line Business Practice Location Address:
8149 KENNEDY AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HIGHLAND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46322-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-923-8540
Provider Business Practice Location Address Fax Number:
219-923-6742
Provider Enumeration Date:
09/20/2006