Provider First Line Business Practice Location Address: 
2314 SASSAFRAS ST
    Provider Second Line Business Practice Location Address: 
2ND FLOOR - ADMIN OFFICE
    Provider Business Practice Location Address City Name: 
ERIE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
16502-2721
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-452-5043
    Provider Business Practice Location Address Fax Number: 
814-452-7005
    Provider Enumeration Date: 
12/07/2005