Provider First Line Business Practice Location Address: 
4100 7TH STREET RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEW KENSINGTON
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15068-7002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-493-2540
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/19/2013