Provider First Line Business Practice Location Address:
3204 CONGRESSIONAL PKWY
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:
46808-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-489-0481
Provider Business Practice Location Address Fax Number:
260-489-7588
Provider Enumeration Date:
02/13/2006