Provider First Line Business Practice Location Address: 
620 WASHINGTON ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HUNTINGDON
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
16652-1722
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-643-0309
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/22/2014