Provider First Line Business Practice Location Address: 
3727 FRONTAGE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MICHIGAN CITY
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46360-7694
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-879-9450
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/30/2016