Provider First Line Business Practice Location Address:
608 GUMPPER AVE
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:
46806-4107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-431-7415
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2026