Provider First Line Business Practice Location Address: 
253 E MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JACKSON
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
45640-1744
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
740-286-3424
    Provider Business Practice Location Address Fax Number: 
740-286-2605
    Provider Enumeration Date: 
08/28/2005