Provider First Line Business Practice Location Address:
3030 LAKE AVE
Provider Second Line Business Practice Location Address:
SUITE 27
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-5428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-5569
Provider Business Practice Location Address Fax Number:
260-422-6086
Provider Enumeration Date:
10/16/2006