Provider First Line Business Practice Location Address:
1610 W COOK RD
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:
46825-3219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-483-3730
Provider Business Practice Location Address Fax Number:
260-489-9782
Provider Enumeration Date:
09/20/2011