Provider First Line Business Practice Location Address:
5104 N CLINTON ST
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:
46825-5720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-2481
Provider Business Practice Location Address Fax Number:
260-969-3067
Provider Enumeration Date:
08/21/2006