Provider First Line Business Practice Location Address: 
6235 E 1100 N
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NORTH MANCHESTER
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46962-8160
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
260-982-0711
    Provider Business Practice Location Address Fax Number: 
260-489-2755
    Provider Enumeration Date: 
02/21/2007