Provider First Line Business Practice Location Address:
819 STATE ROUTE 664 N
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43138-8540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-385-9614
Provider Business Practice Location Address Fax Number:
740-380-2734
Provider Enumeration Date:
06/09/2005