Provider First Line Business Practice Location Address: 
1126 W 4TH ST STE A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LEWISTOWN
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
17044-1909
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-641-4327
    Provider Business Practice Location Address Fax Number: 
814-641-7104
    Provider Enumeration Date: 
10/14/2025