Provider First Line Business Practice Location Address:
302 E JEFFERSON BLVD
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:
46802-3114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-483-6878
Provider Business Practice Location Address Fax Number:
260-471-9234
Provider Enumeration Date:
04/24/2012