Provider First Line Business Practice Location Address: 
2460 FAIRMOUNT BLVD
    Provider Second Line Business Practice Location Address: 
UNIT B
    Provider Business Practice Location Address City Name: 
CLEVELAND HEIGHTS
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
44106-3171
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
216-231-5783
    Provider Business Practice Location Address Fax Number: 
216-231-5907
    Provider Enumeration Date: 
01/05/2006