Provider First Line Business Practice Location Address:
5800 FAIRFIELD AVE STE 112
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:
46807-3453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-255-6034
Provider Business Practice Location Address Fax Number:
260-572-2290
Provider Enumeration Date:
10/31/2025