Provider First Line Business Practice Location Address: 
4126 N HOLLAND SYLVANIA RD
    Provider Second Line Business Practice Location Address: 
SUITE 220
    Provider Business Practice Location Address City Name: 
TOLEDO
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43623
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
419-885-8449
    Provider Business Practice Location Address Fax Number: 
419-882-7621
    Provider Enumeration Date: 
04/21/2020