Provider First Line Business Practice Location Address: 
101 E MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BARNESVILLE
    Provider Business Practice Location Address State Name: 
OH
    Provider Business Practice Location Address Postal Code: 
43713-1005
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
740-239-6447
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/08/2007