Provider First Line Business Practice Location Address: 
420 ELDRIDGE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLUMBUS
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43203-1231
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
614-424-1149
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/04/2016