Provider First Line Business Practice Location Address:
100 W CHICAGO AVE STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST CHICAGO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46312-3261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-392-7016
Provider Business Practice Location Address Fax Number:
219-397-6904
Provider Enumeration Date:
01/20/2025