Provider First Line Business Practice Location Address: 
4204 SUMMERVALE CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MURRYSVILLE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15668-3514
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-858-0768
    Provider Business Practice Location Address Fax Number: 
724-733-0768
    Provider Enumeration Date: 
08/26/2008