Provider First Line Business Practice Location Address:
7972 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 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:
46804-4140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-459-1780
Provider Business Practice Location Address Fax Number:
260-459-2779
Provider Enumeration Date:
12/28/2005