Provider First Line Business Practice Location Address: 
2458 STETZER RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BUCYRUS
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
44820-2066
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
419-562-2000
    Provider Business Practice Location Address Fax Number: 
419-562-1296
    Provider Enumeration Date: 
08/18/2006