Provider First Line Business Practice Location Address:
436 E WASHINGTON BLVD
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:
46802-3210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-209-7111
Provider Business Practice Location Address Fax Number:
260-222-2835
Provider Enumeration Date:
11/04/2005