Provider First Line Business Practice Location Address: 
890 POPLAR CHURCH RD
    Provider Second Line Business Practice Location Address: 
SUITE 405
    Provider Business Practice Location Address City Name: 
CAMP HILL
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
17011-2250
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
717-761-6794
    Provider Business Practice Location Address Fax Number: 
717-761-6808
    Provider Enumeration Date: 
12/04/2014