Provider First Line Business Practice Location Address:
2121 LAKE AVE
Provider Second Line Business Practice Location Address:
DEPARTMENT OF VETERANS AFFAIRS (11)
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-460-1311
Provider Business Practice Location Address Fax Number:
260-421-1827
Provider Enumeration Date:
08/02/2006