Provider First Line Business Practice Location Address:
1221 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:
46825-5887
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-484-2720
Provider Business Practice Location Address Fax Number:
260-471-3488
Provider Enumeration Date:
08/27/2009