Provider First Line Business Practice Location Address: 
425 N 21ST ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CAMP HILL
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
17011-2223
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
717-972-4250
    Provider Business Practice Location Address Fax Number: 
717-972-4249
    Provider Enumeration Date: 
04/20/2015