Provider First Line Business Practice Location Address:
2101 EAST COLISEUM BOULEVARD
Provider Second Line Business Practice Location Address:
NEFF HALL ROOM 109
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-1499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-481-6575
Provider Business Practice Location Address Fax Number:
260-481-4162
Provider Enumeration Date:
05/29/2007