Provider First Line Business Practice Location Address:
1120 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-583-7073
Provider Business Practice Location Address Fax Number:
574-583-9603
Provider Enumeration Date:
09/30/2005