Provider First Line Business Practice Location Address:
3533 MCKINLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46615-3134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-289-7155
Provider Business Practice Location Address Fax Number:
574-289-9755
Provider Enumeration Date:
08/26/2006