Provider First Line Business Practice Location Address:
3401 LAKE AVE
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:
46805-5500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-6396
Provider Business Practice Location Address Fax Number:
260-420-2258
Provider Enumeration Date:
08/23/2005