Provider First Line Business Practice Location Address:
60 RIDGE AVENUE, ROOM 131, WOOD HALL
Provider Second Line Business Practice Location Address:
P.O. 178
Provider Business Practice Location Address City Name:
RIO GRANDE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45674-0178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-245-0593
Provider Business Practice Location Address Fax Number:
740-245-0596
Provider Enumeration Date:
02/23/2009