Provider First Line Business Practice Location Address:
2121 LAKE AVENUE
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:
46805-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-426-5431
Provider Business Practice Location Address Fax Number:
260-421-1834
Provider Enumeration Date:
05/02/2012