Provider First Line Business Practice Location Address:
620 W NORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46725-1214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-244-0202
Provider Business Practice Location Address Fax Number:
260-248-8255
Provider Enumeration Date:
06/15/2006