Provider First Line Business Practice Location Address:
5229 COLDWATER 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:
46825-5538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-484-1453
Provider Business Practice Location Address Fax Number:
260-483-8287
Provider Enumeration Date:
02/23/2006