Provider First Line Business Practice Location Address:
1325 S ANTHONY BLVD
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:
46803-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-424-3420
Provider Business Practice Location Address Fax Number:
260-424-3420
Provider Enumeration Date:
03/12/2007