Provider First Line Business Practice Location Address:
6 CHASE PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46947-1553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-732-1166
Provider Business Practice Location Address Fax Number:
574-753-4117
Provider Enumeration Date:
11/07/2006