Provider First Line Business Practice Location Address:
7802 W. JEFFERSON 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:
46804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-625-6636
Provider Business Practice Location Address Fax Number:
260-459-6625
Provider Enumeration Date:
11/18/2005