Provider First Line Business Practice Location Address:
11123 TRADERS TRACE WAY
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:
46835-0078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-580-5914
Provider Business Practice Location Address Fax Number:
260-580-5914
Provider Enumeration Date:
02/20/2026