Provider First Line Business Practice Location Address: 
110 DANIEL DR
    Provider Second Line Business Practice Location Address: 
SUITE 3
    Provider Business Practice Location Address City Name: 
UNIONTOWN
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15401-8002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-437-0937
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/11/2014