Provider First Line Business Practice Location Address:
718 E BROADWAY
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:
46947-3158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-753-4717
Provider Business Practice Location Address Fax Number:
574-732-1076
Provider Enumeration Date:
07/25/2007