Provider First Line Business Practice Location Address:
100 THIRD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43912-1605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-635-0814
Provider Business Practice Location Address Fax Number:
740-635-2521
Provider Enumeration Date:
10/03/2006