Provider First Line Business Practice Location Address: 
RICHARD L. ROUDEBUSH VA MEDICAL CENTER
    Provider Second Line Business Practice Location Address: 
1481 WEST 10TH STREET
    Provider Business Practice Location Address City Name: 
INDIANAPOLIS
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46202
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
317-988-1414
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/22/2014