Provider First Line Business Practice Location Address: 
7777 U.S. ROUTE 23
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PIKETON
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
45661
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
740-289-3508
    Provider Business Practice Location Address Fax Number: 
740-289-8951
    Provider Enumeration Date: 
06/02/2009