Provider First Line Business Practice Location Address: 
3928 WASHINGTON RD
    Provider Second Line Business Practice Location Address: 
SUITE 230
    Provider Business Practice Location Address City Name: 
MC MURRAY
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15317-2537
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-941-1866
    Provider Business Practice Location Address Fax Number: 
724-941-1647
    Provider Enumeration Date: 
02/12/2007