Provider First Line Business Practice Location Address: 
550 S COLLEGE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RENSSELAER
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
47978-3007
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-866-4156
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/11/2011