Provider First Line Business Practice Location Address: 
915 MILLS DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NORTH HUNTINGDON
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15642-4129
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-382-3165
    Provider Business Practice Location Address Fax Number: 
724-866-1045
    Provider Enumeration Date: 
04/13/2006