Provider First Line Business Practice Location Address:
12101 LIMA RD
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:
46818-8903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-637-3166
Provider Business Practice Location Address Fax Number:
260-637-3536
Provider Enumeration Date:
04/18/2007