Provider First Line Business Practice Location Address: 
2628 STATE ROUTE 325 N
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BIDWELL
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
45614-9109
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
740-441-7967
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/14/2008