Provider First Line Business Practice Location Address:
9502 LIMA ROAD
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46818-9270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-459-7313
Provider Business Practice Location Address Fax Number:
260-436-0628
Provider Enumeration Date:
08/11/2005