Provider First Line Business Practice Location Address:
11123 PARKVIEW PLAZA DR.
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-672-6520
Provider Business Practice Location Address Fax Number:
260-490-6261
Provider Enumeration Date:
06/25/2006