Provider First Line Business Practice Location Address:
1272 W MAIN ST
Provider Second Line Business Practice Location Address:
BLDG. 5
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43055-2034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-348-1788
Provider Business Practice Location Address Fax Number:
740-348-1789
Provider Enumeration Date:
07/13/2005