Provider First Line Business Practice Location Address: 
518 LINCOLN WAY W
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MISHAWAKA
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46544-1807
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
574-255-5630
    Provider Business Practice Location Address Fax Number: 
574-256-0323
    Provider Enumeration Date: 
02/20/2007