Provider First Line Business Practice Location Address:
1747 N WELLS ST
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:
46808-3235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-420-6100
Provider Business Practice Location Address Fax Number:
574-268-2377
Provider Enumeration Date:
08/20/2010