Provider First Line Business Practice Location Address:
11115 LIMA RD
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:
46818-9536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-489-6544
Provider Business Practice Location Address Fax Number:
260-416-0544
Provider Enumeration Date:
03/27/2007