Provider First Line Business Practice Location Address: 
256 N WOODBRIDGE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHILLICOTHEE
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
45601-2245
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
740-775-6788
    Provider Business Practice Location Address Fax Number: 
740-775-6792
    Provider Enumeration Date: 
08/03/2006