Provider First Line Business Practice Location Address:
819 STATE ROUTE 664 N STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43138-8540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-380-8171
Provider Business Practice Location Address Fax Number:
740-380-8396
Provider Enumeration Date:
04/18/2007