Provider First Line Business Practice Location Address:
3010 E STATE 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:
46805-4700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-496-9940
Provider Business Practice Location Address Fax Number:
260-496-8971
Provider Enumeration Date:
02/07/2007