Provider First Line Business Practice Location Address: 
6136 MECHANICSVILLE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MECHANICSVILLE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18934-9520
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
267-278-6139
    Provider Business Practice Location Address Fax Number: 
215-297-5379
    Provider Enumeration Date: 
10/16/2012