Provider First Line Business Practice Location Address:
1837 GOUCHER ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15905-9506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-255-7292
Provider Business Practice Location Address Fax Number:
814-255-6742
Provider Enumeration Date:
10/25/2006