Provider First Line Business Practice Location Address:
1226 LEXINGTON 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:
46807-2133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-446-1449
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2025