Provider First Line Business Practice Location Address:
9512 LIMA RD STE 103
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:
46818-9806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-414-4713
Provider Business Practice Location Address Fax Number:
260-489-2226
Provider Enumeration Date:
07/26/2011