Provider First Line Business Practice Location Address: 
1206 E MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DELTA
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43515-1461
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
419-822-3660
    Provider Business Practice Location Address Fax Number: 
149-822-4413
    Provider Enumeration Date: 
07/09/2006