Provider First Line Business Practice Location Address: 
161 E OTTERMAN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GREENSBURG
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15601-2578
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-836-5199
    Provider Business Practice Location Address Fax Number: 
724-836-5699
    Provider Enumeration Date: 
07/24/2006