Provider First Line Business Practice Location Address: 
3459 SEABROOK AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLUMBUS
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43227-3243
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
614-282-1511
    Provider Business Practice Location Address Fax Number: 
614-418-9100
    Provider Enumeration Date: 
08/31/2015