Provider First Line Business Practice Location Address: 
726 FRANKLIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SHOEMAKERSVILLE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19555-1619
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
610-451-4514
    Provider Business Practice Location Address Fax Number: 
610-796-9130
    Provider Enumeration Date: 
01/12/2015