Provider First Line Business Practice Location Address:
4118 N CLINTON ST
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:
46805-1210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-493-3400
Provider Business Practice Location Address Fax Number:
260-749-2731
Provider Enumeration Date:
09/10/2010