Provider First Line Business Practice Location Address:
2700 LAFAYETTE ST
Provider Second Line Business Practice Location Address:
STE B-10
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46806-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-744-7004
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2006