Provider First Line Business Practice Location Address:
4656 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-6857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-969-0915
Provider Business Practice Location Address Fax Number:
260-969-0917
Provider Enumeration Date:
10/15/2010