Provider First Line Business Practice Location Address:
142 E COLLINS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-5302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-471-5011
Provider Business Practice Location Address Fax Number:
260-471-5109
Provider Enumeration Date:
01/04/2006