Provider First Line Business Practice Location Address:
3968 E MARKET ST
Provider Second Line Business Practice Location Address:
SPACE C-9
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-2239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-739-2708
Provider Business Practice Location Address Fax Number:
574-753-2082
Provider Enumeration Date:
05/17/2006