Provider First Line Business Practice Location Address:
3520 ACADEMIC PL APT 303
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:
46835-5318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-205-4116
Provider Business Practice Location Address Fax Number:
260-205-4116
Provider Enumeration Date:
01/23/2026