Provider First Line Business Practice Location Address: 
3570 WASHINGTON PIKE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BRIDGEVILLE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15017-1089
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
412-257-2474
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/08/2014