Provider First Line Business Practice Location Address:
203W WAYNE ST 317
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:
46802-3610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-413-0040
Provider Business Practice Location Address Fax Number:
260-344-2820
Provider Enumeration Date:
07/20/2005