Provider First Line Business Practice Location Address:
1115 E BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-3253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-722-4910
Provider Business Practice Location Address Fax Number:
574-722-2652
Provider Enumeration Date:
05/08/2008