Provider First Line Business Practice Location Address:
1830 WAYNE TRCE
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:
46803-2657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-415-5593
Provider Business Practice Location Address Fax Number:
260-201-9894
Provider Enumeration Date:
10/29/2025