Provider First Line Business Practice Location Address: 
30 OLD MONONGAHELA PIKE
    Provider Second Line Business Practice Location Address: 
SUITE 6
    Provider Business Practice Location Address City Name: 
EIGHTY FOUR
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15330-3539
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-395-2233
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/28/2022