Provider First Line Business Practice Location Address: 
208 S MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MOSCOW
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18444-9135
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
570-842-9323
    Provider Business Practice Location Address Fax Number: 
570-842-9362
    Provider Enumeration Date: 
10/22/2014