Provider First Line Business Practice Location Address: 
2403 US HIGHWAY 31 LOT 15
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PLYMOUTH
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
46563-7315
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
574-780-7772
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/12/2015