Provider First Line Business Practice Location Address: 
1640 TIFFIN AVE
    Provider Second Line Business Practice Location Address: 
SUITE B
    Provider Business Practice Location Address City Name: 
FINDLAY
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
45840-6849
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
567-429-9309
    Provider Business Practice Location Address Fax Number: 
419-422-7673
    Provider Enumeration Date: 
12/08/2014