Provider First Line Business Practice Location Address: 
114 SOUTH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
QUINCY
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43343
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
937-538-7619
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/28/2016