Provider First Line Business Practice Location Address:
10701 US 23 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUCASVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-259-0300
Provider Business Practice Location Address Fax Number:
740-259-6191
Provider Enumeration Date:
05/23/2011