Provider First Line Business Practice Location Address:
2020 MCKINNIE AVE STE 200
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:
46806-4975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-399-3809
Provider Business Practice Location Address Fax Number:
260-800-5754
Provider Enumeration Date:
07/10/2025