Provider First Line Business Practice Location Address: 
4565 MONROE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TOLEDO
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43613-4709
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
586-482-0319
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/18/2010