Provider First Line Business Practice Location Address:
321 E WAYNE 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:
46802-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-5976
Provider Business Practice Location Address Fax Number:
260-969-1041
Provider Enumeration Date:
07/05/2006