Provider First Line Business Practice Location Address:
2910 LAKE AVE
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:
46805-5416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-420-1935
Provider Business Practice Location Address Fax Number:
260-420-1876
Provider Enumeration Date:
09/06/2006