Provider First Line Business Practice Location Address:
1405 MEDICAL PARK DR
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:
46825-5831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-482-4483
Provider Business Practice Location Address Fax Number:
260-471-9889
Provider Enumeration Date:
11/13/2007