Provider First Line Business Practice Location Address:
616 W SUPERIOR ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46802-1000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-426-2255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/26/2006