Provider First Line Business Practice Location Address:
228D, EAST COLLINS ROAD
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:
46825-5394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-471-7675
Provider Business Practice Location Address Fax Number:
260-471-0701
Provider Enumeration Date:
05/03/2007