Provider First Line Business Practice Location Address:
122 W WASHINGTON BLVD
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-423-2521
Provider Business Practice Location Address Fax Number:
260-423-6314
Provider Enumeration Date:
12/18/2006