Provider First Line Business Practice Location Address:
528 W WASHINGTON 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:
46802-2918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-426-4357
Provider Business Practice Location Address Fax Number:
260-426-0485
Provider Enumeration Date:
07/31/2006