Provider First Line Business Practice Location Address: 
650 CHERRY TREE LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
UNIONTOWN
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15401-8947
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-438-4364
    Provider Business Practice Location Address Fax Number: 
724-438-4720
    Provider Enumeration Date: 
11/02/2005