Provider First Line Business Practice Location Address:
1201 MICHIGAN AVE STE LL50
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-1562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-753-1407
Provider Business Practice Location Address Fax Number:
574-753-1489
Provider Enumeration Date:
07/19/2019