Provider First Line Business Practice Location Address:
200 26TH ST
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:
46947-2063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-722-4006
Provider Business Practice Location Address Fax Number:
574-753-8753
Provider Enumeration Date:
07/26/2006