Provider First Line Business Practice Location Address:
1816 CALIFORNIA 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:
46805-5024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-750-9678
Provider Business Practice Location Address Fax Number:
260-387-7413
Provider Enumeration Date:
06/20/2005