Provider First Line Business Practice Location Address: 
332 W 806 N
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VALPARAISO
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46385-7973
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-764-4888
    Provider Business Practice Location Address Fax Number: 
219-764-7676
    Provider Enumeration Date: 
08/31/2011