Provider First Line Business Practice Location Address:
1900 W 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47620-9407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-838-5526
Provider Business Practice Location Address Fax Number:
812-838-6757
Provider Enumeration Date:
12/19/2005