Provider First Line Business Practice Location Address:
2121 LAKE AVE
Provider Second Line Business Practice Location Address:
VA NIHCS, HBPC
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-460-1376
Provider Business Practice Location Address Fax Number:
260-460-1482
Provider Enumeration Date:
08/16/2006