Provider First Line Business Practice Location Address:
1807 SMITH ST
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:
46947-1576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-732-1414
Provider Business Practice Location Address Fax Number:
574-732-0504
Provider Enumeration Date:
04/19/2008