Provider First Line Business Practice Location Address:
1411 S. WOODLAND AVENUE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MICHIGAN CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46360-7170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-763-1499
Provider Business Practice Location Address Fax Number:
219-764-7025
Provider Enumeration Date:
10/06/2009