Provider First Line Business Practice Location Address: 
1370 WASHINGTON PIKE
    Provider Second Line Business Practice Location Address: 
SUITE 303
    Provider Business Practice Location Address City Name: 
BRIDGEVILLE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15017-2862
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
412-206-0123
    Provider Business Practice Location Address Fax Number: 
412-206-0128
    Provider Enumeration Date: 
07/17/2006