Provider First Line Business Practice Location Address: 
102 EQUITY DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GREENSBURG
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15601-7190
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-836-2460
    Provider Business Practice Location Address Fax Number: 
724-836-4235
    Provider Enumeration Date: 
05/02/2006