Provider First Line Business Practice Location Address:
226 E COLLINS 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:
46825-5395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-414-7734
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2026