Provider First Line Business Practice Location Address:
2100 GOSHEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46808-1493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-471-3500
Provider Business Practice Location Address Fax Number:
260-471-4263
Provider Enumeration Date:
11/29/2006