Provider First Line Business Practice Location Address:
2414 SOUTH SAINT ANTHONY ROAD NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT ANTHONY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47575-9747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-639-0027
Provider Business Practice Location Address Fax Number:
812-326-2409
Provider Enumeration Date:
07/19/2007