Provider First Line Business Practice Location Address:
415 E COOK RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-3636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-489-6030
Provider Business Practice Location Address Fax Number:
260-489-5536
Provider Enumeration Date:
12/08/2006