Provider First Line Business Practice Location Address: 
15 EAST MAIN STREET
    Provider Second Line Business Practice Location Address: 
SUITE C
    Provider Business Practice Location Address City Name: 
LEXINGTON
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
44904-0181
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
419-884-1566
    Provider Business Practice Location Address Fax Number: 
419-884-1522
    Provider Enumeration Date: 
10/04/2006