Provider First Line Business Practice Location Address:
130 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE L
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46802-1712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-418-1816
Provider Business Practice Location Address Fax Number:
877-418-1816
Provider Enumeration Date:
11/21/2007