Provider First Line Business Practice Location Address:
2710 LAKE 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:
46805-5412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-481-2700
Provider Business Practice Location Address Fax Number:
260-969-8448
Provider Enumeration Date:
12/06/2007