Provider First Line Business Practice Location Address: 
1555 BETHEL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLUMBUS
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43220-2003
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
614-442-0664
    Provider Business Practice Location Address Fax Number: 
614-442-0620
    Provider Enumeration Date: 
01/15/2007