Provider First Line Business Practice Location Address: 
2478 PAINTED DESERT RUN
    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: 
46808-3660
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
219-916-4732
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/02/2025