Provider First Line Business Practice Location Address:
850 BRAINARD RD STE 1F
Provider Second Line Business Practice Location Address:
C/O GREAT LAKES BILLING
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44143-3145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-605-9117
Provider Business Practice Location Address Fax Number:
440-442-4443
Provider Enumeration Date:
11/19/2009