Provider First Line Business Practice Location Address:
1201 DEFIANCE ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WAPAKONETA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45895-1059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-738-2715
Provider Business Practice Location Address Fax Number:
419-738-2815
Provider Enumeration Date:
09/06/2006