Provider First Line Business Practice Location Address:
200 ALFRED ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MICHIGAN CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-872-6200
Provider Business Practice Location Address Fax Number:
219-879-2915
Provider Enumeration Date:
11/07/2005