Provider First Line Business Practice Location Address:
10020 LIMA RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46818-9144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-490-8485
Provider Business Practice Location Address Fax Number:
260-490-9874
Provider Enumeration Date:
07/20/2005