Provider First Line Business Practice Location Address: 
103 5TH ST SE STE M
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BARBERTON
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
44203-4256
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-512-0001
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/28/2017