Provider First Line Business Practice Location Address:
4656 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-6857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-432-3588
Provider Business Practice Location Address Fax Number:
260-459-0729
Provider Enumeration Date:
09/14/2006