Provider First Line Business Practice Location Address:
959 ILLINOIS AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MAUMEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43537-1743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-482-6519
Provider Business Practice Location Address Fax Number:
419-482-6832
Provider Enumeration Date:
11/19/2009