Provider First Line Business Practice Location Address: 
550 S LANDMARK AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BLOOMINGTON
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
47403-3239
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
812-330-3689
    Provider Business Practice Location Address Fax Number: 
812-331-3656
    Provider Enumeration Date: 
06/17/2005