Provider First Line Business Practice Location Address:
3402 CONGRESSIONAL PKWY STE A
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:
46808-4440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-444-3071
Provider Business Practice Location Address Fax Number:
2-280-8448
Provider Enumeration Date:
05/07/2008