Provider First Line Business Practice Location Address: 
1135 HAMPDEN PLACE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
STRAUSBURG
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
17579-1123
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
717-687-3604
    Provider Business Practice Location Address Fax Number: 
717-687-3604
    Provider Enumeration Date: 
01/05/2016