Provider First Line Business Practice Location Address:
7920 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-4168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-432-7600
Provider Business Practice Location Address Fax Number:
260-436-8498
Provider Enumeration Date:
02/22/2007