Provider First Line Business Practice Location Address:
4109 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-6894
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-486-5251
Provider Business Practice Location Address Fax Number:
260-486-5058
Provider Enumeration Date:
09/13/2005