Provider First Line Business Practice Location Address: 
4848 HOLLAND SYLVANIA ROAD
    Provider Second Line Business Practice Location Address: 
201
    Provider Business Practice Location Address City Name: 
SYLVANIA
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43560
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
419-885-1230
    Provider Business Practice Location Address Fax Number: 
419-882-6027
    Provider Enumeration Date: 
07/18/2005