Provider First Line Business Practice Location Address: 
348 BUDFIELD STREET
    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: 
15904-3214
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-262-3950
    Provider Business Practice Location Address Fax Number: 
814-262-3990
    Provider Enumeration Date: 
08/10/2006