Provider First Line Business Practice Location Address: 
1270E POWELL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LEWIS CENTER
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43035-8619
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
614-432-6401
    Provider Business Practice Location Address Fax Number: 
614-543-1363
    Provider Enumeration Date: 
12/22/2014