Provider First Line Business Practice Location Address:
1114 W COOK RD
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:
46825-3214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-483-5588
Provider Business Practice Location Address Fax Number:
260-489-1819
Provider Enumeration Date:
01/11/2008