Provider First Line Business Practice Location Address: 
1700 BOETTLER RD
    Provider Second Line Business Practice Location Address: 
STE. 100
    Provider Business Practice Location Address City Name: 
UNIONTOWN
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
44685-7792
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
330-896-0009
    Provider Business Practice Location Address Fax Number: 
330-896-0032
    Provider Enumeration Date: 
01/02/2008