Provider First Line Business Practice Location Address:
5050 N CLINTON 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:
46825-5886
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-484-8551
Provider Business Practice Location Address Fax Number:
260-482-5060
Provider Enumeration Date:
11/30/2005