Provider First Line Business Practice Location Address:
16 W LONG ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43215-2815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-225-0990
Provider Business Practice Location Address Fax Number:
614-225-0988
Provider Enumeration Date:
02/11/2026