Provider First Line Business Practice Location Address:
930 BROADWAY
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:
46802-2110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-266-0780
Provider Business Practice Location Address Fax Number:
260-266-0785
Provider Enumeration Date:
10/28/2026