Provider First Line Business Practice Location Address:
405 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHIPPENVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16254-0100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-297-8400
Provider Business Practice Location Address Fax Number:
814-782-3957
Provider Enumeration Date:
08/29/2005