Provider First Line Business Practice Location Address: 
285 BIELBY RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAWRENCEBURG
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
47025-1055
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
812-537-1302
    Provider Business Practice Location Address Fax Number: 
812-537-5219
    Provider Enumeration Date: 
01/16/2007