Provider First Line Business Practice Location Address: 
20 SHERATON DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALTOONA
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
16601-9316
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-941-1384
    Provider Business Practice Location Address Fax Number: 
814-941-1628
    Provider Enumeration Date: 
10/03/2012