Provider First Line Business Practice Location Address:
1611 27TH ST
Provider Second Line Business Practice Location Address:
BLDG. J, SUITE 102
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45662-6931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-353-3189
Provider Business Practice Location Address Fax Number:
740-353-7672
Provider Enumeration Date:
12/19/2006