Provider First Line Business Practice Location Address:
11932 LIMA RD
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:
46818-8658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-637-6667
Provider Business Practice Location Address Fax Number:
260-637-6822
Provider Enumeration Date:
09/30/2011