Provider First Line Business Practice Location Address: 
8691 CONNECTICUT ST STE B
    Provider Second Line Business Practice Location Address: 
SUITE B
    Provider Business Practice Location Address City Name: 
MERRILLVILLE
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46410-6222
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-793-1900
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/20/2006