Provider First Line Business Practice Location Address:
7802 W. JEFFERSON BLVD. #B
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:
46804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-999-6924
Provider Business Practice Location Address Fax Number:
260-222-2844
Provider Enumeration Date:
12/02/2010