Provider First Line Business Practice Location Address:
405 W WAYNE ST
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:
46802-2121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-3717
Provider Business Practice Location Address Fax Number:
260-918-6649
Provider Enumeration Date:
01/12/2011