Provider First Line Business Practice Location Address: 
2318 FREEPORT RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NATRONA HEIGHTS
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15065-1651
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-757-6119
    Provider Business Practice Location Address Fax Number: 
724-409-6060
    Provider Enumeration Date: 
10/10/2012