Provider First Line Business Practice Location Address: 
1097 GEORGES FAIRCHANCE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SMITHFIELD
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15478-1595
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-564-9729
    Provider Business Practice Location Address Fax Number: 
724-564-0599
    Provider Enumeration Date: 
10/27/2006