Provider First Line Business Practice Location Address: 
1029 COUNTRY CLUB RD
    Provider Second Line Business Practice Location Address: 
SUITE 201
    Provider Business Practice Location Address City Name: 
MONONGAHELA
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15063-1564
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-565-4575
    Provider Business Practice Location Address Fax Number: 
724-258-2366
    Provider Enumeration Date: 
09/25/2014