Provider First Line Business Practice Location Address:
3515 W 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:
46808-1724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-699-7149
Provider Business Practice Location Address Fax Number:
260-279-2405
Provider Enumeration Date:
12/10/2025