Provider First Line Business Practice Location Address:
7845 CARNEGIE 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:
46804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-969-4105
Provider Business Practice Location Address Fax Number:
260-969-4118
Provider Enumeration Date:
11/21/2006