Provider First Line Business Practice Location Address: 
5800 MONROE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SYLVANIA
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43560-2263
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
419-824-3433
    Provider Business Practice Location Address Fax Number: 
419-824-0216
    Provider Enumeration Date: 
10/02/2008