Provider First Line Business Practice Location Address: 
4207 LAKE AVE
    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: 
46815-7219
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
260-426-3401
    Provider Business Practice Location Address Fax Number: 
260-424-3007
    Provider Enumeration Date: 
10/15/2006