Provider First Line Business Practice Location Address:
604 W. BERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46802-2106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-423-1331
Provider Business Practice Location Address Fax Number:
260-422-1046
Provider Enumeration Date:
04/23/2007