Provider First Line Business Practice Location Address:
320 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15901-4305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-410-8296
Provider Business Practice Location Address Fax Number:
814-410-8597
Provider Enumeration Date:
11/15/2006