Provider First Line Business Practice Location Address:
1634 11TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTSMOUTH1
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-354-6685
Provider Business Practice Location Address Fax Number:
740-354-5061
Provider Enumeration Date:
08/31/2012