Provider First Line Business Practice Location Address:
1010 W WASHINGTON CENTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-4155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-489-2552
Provider Business Practice Location Address Fax Number:
260-487-9912
Provider Enumeration Date:
10/03/2005