Provider First Line Business Practice Location Address: 
1700 OLD GATESBURG ROAD
    Provider Second Line Business Practice Location Address: 
SUITE 210
    Provider Business Practice Location Address City Name: 
STATE COLLEGE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
16803
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-278-1912
    Provider Business Practice Location Address Fax Number: 
814-278-1921
    Provider Enumeration Date: 
08/28/2012