Provider First Line Business Practice Location Address:
2200 LAKE AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-5397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-385-0713
Provider Business Practice Location Address Fax Number:
260-422-8783
Provider Enumeration Date:
01/25/2007