Provider First Line Business Practice Location Address:
3101 OLD HOBART RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE STATION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46405-2351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-588-3866
Provider Business Practice Location Address Fax Number:
219-963-6260
Provider Enumeration Date:
02/14/2026