Provider First Line Business Practice Location Address:
3010 E. STATE BLVD
Provider Second Line Business Practice Location Address:
STE 100
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-471-0632
Provider Business Practice Location Address Fax Number:
260-471-3451
Provider Enumeration Date:
05/15/2006