Provider First Line Business Practice Location Address: 
2460 FAIRMOUNT BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 320
    Provider Business Practice Location Address City Name: 
CLEVELAND HEIGHTS
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
44106-3164
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
440-779-6773
    Provider Business Practice Location Address Fax Number: 
216-231-7235
    Provider Enumeration Date: 
10/26/2006