Provider First Line Business Practice Location Address:
920 W COUNTY LINE RD N
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:
46818-9120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-625-4626
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2006