Provider First Line Business Practice Location Address:
496 GLENWOOD AVE
Provider Second Line Business Practice Location Address:
SUITE 136
Provider Business Practice Location Address City Name:
YOUNGSTOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44502-1509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-740-0402
Provider Business Practice Location Address Fax Number:
330-740-0432
Provider Enumeration Date:
10/26/2012