Provider First Line Business Practice Location Address:
1240 MEDICAL PARK DR
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:
46825-5828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-471-2375
Provider Business Practice Location Address Fax Number:
260-484-3367
Provider Enumeration Date:
04/05/2006