Provider First Line Business Practice Location Address: 
600 MEDICAL ARTS BLDG
    Provider Second Line Business Practice Location Address: 
STE 640
    Provider Business Practice Location Address City Name: 
KITTANNING
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
16201-7134
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-543-8577
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/10/2010