Provider First Line Business Practice Location Address:
609 STATE ROUTE 664 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43138-8541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-385-0919
Provider Business Practice Location Address Fax Number:
740-385-8439
Provider Enumeration Date:
08/21/2006