Provider First Line Business Practice Location Address: 
4230 CRUMS MILL RD STE 201
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HARRISBURG
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
17112
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
717-579-4878
    Provider Business Practice Location Address Fax Number: 
717-540-1704
    Provider Enumeration Date: 
05/03/2018