Provider First Line Business Practice Location Address:
2121 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:
46805-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-460-1456
Provider Business Practice Location Address Fax Number:
260-421-1029
Provider Enumeration Date:
12/31/2007