Provider First Line Business Practice Location Address:
5933 E STATE BLVD
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:
46815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-485-1231
Provider Business Practice Location Address Fax Number:
260-486-6958
Provider Enumeration Date:
02/21/2007