Provider First Line Business Practice Location Address:
1600 E WASHINGTON 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:
46803-1228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-5561
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006