Provider First Line Business Practice Location Address: 
689 APP RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SELINSGROVE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
17870-7637
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
570-884-8201
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/21/2011