Provider First Line Business Practice Location Address: 
1125 ELLEN KAY DR
    Provider Second Line Business Practice Location Address: 
SUITE B
    Provider Business Practice Location Address City Name: 
MARION
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43302-6286
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
740-387-3087
    Provider Business Practice Location Address Fax Number: 
740-382-5034
    Provider Enumeration Date: 
10/06/2006