Provider First Line Business Practice Location Address: 
6910 N MAIN ST
    Provider Second Line Business Practice Location Address: 
UNIT 31, SUITE 12H
    Provider Business Practice Location Address City Name: 
GRANGER
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46530-9680
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
269-782-2489
    Provider Business Practice Location Address Fax Number: 
269-782-2489
    Provider Enumeration Date: 
02/16/2007