Provider First Line Business Practice Location Address:
205 E WASHINGTON CENTER RD
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:
46825-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-482-2586
Provider Business Practice Location Address Fax Number:
260-471-5949
Provider Enumeration Date:
10/18/2012