Provider First Line Business Practice Location Address:
11123 PARKVIEW PLAZA DR.
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46845-1545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-7455
Provider Business Practice Location Address Fax Number:
260-422-4125
Provider Enumeration Date:
12/28/2009