Provider First Line Business Practice Location Address:
732 S SHOOP AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUSEON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43567-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-337-2399
Provider Business Practice Location Address Fax Number:
419-337-5392
Provider Enumeration Date:
06/30/2005