Provider First Line Business Practice Location Address: 
302 INDUSTRIAL DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AVONDALE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19311-9769
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
610-910-9580
    Provider Business Practice Location Address Fax Number: 
610-537-5055
    Provider Enumeration Date: 
12/05/2014