Provider First Line Business Practice Location Address:
321 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 4H
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15901-1632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-535-1234
Provider Business Practice Location Address Fax Number:
814-535-4321
Provider Enumeration Date:
05/20/2006