Provider First Line Business Practice Location Address: 
32 CENTRAL AVENUE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WELLSBORO
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
16901
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-558-4662
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/19/2019