Provider First Line Business Practice Location Address:
1220 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-5843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-482-9196
Provider Business Practice Location Address Fax Number:
260-484-3371
Provider Enumeration Date:
06/17/2005