Provider First Line Business Practice Location Address: 
10 LOUIS ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PLAINS
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18705-3911
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
570-407-4022
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/26/2016