Provider First Line Business Practice Location Address:
233 W MAIN ST
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:
46802-1613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-426-0060
Provider Business Practice Location Address Fax Number:
260-426-0264
Provider Enumeration Date:
02/23/2007