Provider First Line Business Practice Location Address: 
4383 HECKTOWN RD
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
BETHLEHEM
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18020-9767
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
484-293-0088
    Provider Business Practice Location Address Fax Number: 
484-293-0228
    Provider Enumeration Date: 
09/15/2009