Provider First Line Business Practice Location Address:
236 ELM DRIVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
WAYNESBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-627-2673
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2010