Provider First Line Business Practice Location Address: 
88 N PLAINS RD STE 104B
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
THE PLAINS
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
45780-1162
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
740-331-4040
    Provider Business Practice Location Address Fax Number: 
740-331-4208
    Provider Enumeration Date: 
12/01/2006