Provider First Line Business Practice Location Address:
2101 E. COLISEUM BLVD
Provider Second Line Business Practice Location Address:
WALB STUDENT UNION ROOM 234
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-494-0111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2015