Provider First Line Business Practice Location Address:
2927 LAKE AVE
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:
46805-5415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-745-1200
Provider Business Practice Location Address Fax Number:
260-456-1066
Provider Enumeration Date:
03/06/2007