Provider First Line Business Practice Location Address:
2470 LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-5406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-424-2195
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/16/2005