Provider First Line Business Practice Location Address:
5436 OLD MAUMEE RD
Provider Second Line Business Practice Location Address:
UNIT 1
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46803-1713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-748-7711
Provider Business Practice Location Address Fax Number:
260-748-7877
Provider Enumeration Date:
03/28/2009