Provider First Line Business Practice Location Address:
4630 W JEFFERSON BLVD STE 5
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:
46804-6800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-436-4100
Provider Business Practice Location Address Fax Number:
260-432-6282
Provider Enumeration Date:
06/22/2005