Provider First Line Business Practice Location Address:
12124 LIMA RD STE 100
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:
46818-9508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-637-4392
Provider Business Practice Location Address Fax Number:
260-637-1554
Provider Enumeration Date:
01/12/2009