Provider First Line Business Practice Location Address:
41 S LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH EAST
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16428-1239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-835-8258
Provider Business Practice Location Address Fax Number:
814-838-0104
Provider Enumeration Date:
08/17/2010