Provider First Line Business Practice Location Address: 
885 N SANDUSKY AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
UPPER SANDUSKY
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43351-1031
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
419-294-1973
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/18/2006