Provider First Line Business Practice Location Address:
3501 FAIRFIELD AVE
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:
46807-1805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-249-9269
Provider Business Practice Location Address Fax Number:
260-745-2500
Provider Enumeration Date:
12/05/2008