Provider First Line Business Practice Location Address:
624 E 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:
46802-2016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-557-7004
Provider Business Practice Location Address Fax Number:
260-338-0584
Provider Enumeration Date:
12/26/2007