Provider First Line Business Practice Location Address: 
857 W. WALNUT STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COAL TOWNSHIP
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
17866-1517
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-771-1788
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/25/2011