Provider First Line Business Practice Location Address: 
42 TOMPKINS AVENUE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLUMBUS
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43202
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
614-725-2118
    Provider Business Practice Location Address Fax Number: 
614-725-2138
    Provider Enumeration Date: 
09/07/2010