Provider First Line Business Practice Location Address:
6049 E STATE BLVD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46815-7638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-485-3100
Provider Business Practice Location Address Fax Number:
260-485-3133
Provider Enumeration Date:
11/10/2005