Provider First Line Business Practice Location Address:
205 NORTH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUCASVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45648-0400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-259-0281
Provider Business Practice Location Address Fax Number:
740-259-0282
Provider Enumeration Date:
05/20/2006