Provider First Line Business Practice Location Address:
800 BROADWAY
Provider Second Line Business Practice Location Address:
STE 207
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46802-2149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-2386
Provider Business Practice Location Address Fax Number:
260-422-3985
Provider Enumeration Date:
09/11/2006