Provider First Line Business Practice Location Address:
7916 W. JEFFERSON BLVD.
Provider Second Line Business Practice Location Address:
STE 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:
46804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-432-2297
Provider Business Practice Location Address Fax Number:
260-434-6420
Provider Enumeration Date:
07/09/2006