Provider First Line Business Practice Location Address:
5014 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:
46804-6804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-432-4060
Provider Business Practice Location Address Fax Number:
260-436-7475
Provider Enumeration Date:
07/12/2005