Provider First Line Business Practice Location Address: 
39 E GARFIELD AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DU BOIS
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15801-3101
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-371-1238
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/15/2008