Provider First Line Business Practice Location Address:
1320 N COLISEUM BLVD
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:
46805-5526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-401-8142
Provider Business Practice Location Address Fax Number:
574-401-8143
Provider Enumeration Date:
08/19/2026