Provider First Line Business Practice Location Address: 
118 SOMERSET ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FREEMANSBURG
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18017-7258
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
610-614-1220
    Provider Business Practice Location Address Fax Number: 
610-614-1224
    Provider Enumeration Date: 
03/05/2007