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: 
260-471-2000
    Provider Business Practice Location Address Fax Number: 
260-471-2100
    Provider Enumeration Date: 
10/09/2021