Provider First Line Business Practice Location Address:
17273 STATE ROUTE 104
Provider Second Line Business Practice Location Address:
BLUE TEAM (11C)
Provider Business Practice Location Address City Name:
CHILLICOTHEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45601-8605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-773-1141
Provider Business Practice Location Address Fax Number:
740-772-7077
Provider Enumeration Date:
12/20/2006