Provider First Line Business Practice Location Address: 
93 E PENN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WERNERSVILLE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19565-1628
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
610-678-8395
    Provider Business Practice Location Address Fax Number: 
610-678-0172
    Provider Enumeration Date: 
02/03/2015