Provider First Line Business Practice Location Address:
2200 LAKE AVE
Provider Second Line Business Practice Location Address:
SUITE 260
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:
260-424-0411
Provider Business Practice Location Address Fax Number:
260-424-3530
Provider Enumeration Date:
07/31/2007