Provider First Line Business Practice Location Address:
330 LOUISIANA AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
PERRYSBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43551-1470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-356-6966
Provider Business Practice Location Address Fax Number:
419-873-0892
Provider Enumeration Date:
10/19/2005