Provider First Line Business Practice Location Address: 
345 TUXEDO AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BROOKLYN HEIGHTS
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
44131-1109
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
216-351-3542
    Provider Business Practice Location Address Fax Number: 
216-749-0892
    Provider Enumeration Date: 
07/18/2006