Provider First Line Business Practice Location Address:
2110 LOWER HUNTINGTON 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:
46819-1235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-478-9960
Provider Business Practice Location Address Fax Number:
260-478-9670
Provider Enumeration Date:
09/19/2006