Provider First Line Business Practice Location Address:
6424 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-6204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-969-1400
Provider Business Practice Location Address Fax Number:
260-969-0322
Provider Enumeration Date:
11/09/2006