Provider First Line Business Practice Location Address: 
307 VINE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JOHNSTOWN
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15901-2906
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-288-4961
    Provider Business Practice Location Address Fax Number: 
814-809-8479
    Provider Enumeration Date: 
02/17/2015