Provider First Line Business Practice Location Address:
2121 LAKE AVE.
Provider Second Line Business Practice Location Address:
VA NORTHERN INDIANA HEALTH CARE SYSTEM
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
56805-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-426-5431
Provider Business Practice Location Address Fax Number:
260-460-1482
Provider Enumeration Date:
09/02/2005