Provider First Line Business Practice Location Address: 
146 FOREST HILL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BOARDMAN
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
44512-1439
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
330-782-2438
    Provider Business Practice Location Address Fax Number: 
330-782-2591
    Provider Enumeration Date: 
09/15/2006