Provider First Line Business Practice Location Address: 
4211 HICKORY HILL AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LORAIN
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
44052-5607
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
440-989-8441
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/25/2007