Provider First Line Business Practice Location Address: 
32-36 CENTRAL AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WELLSBORO
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
16901-1840
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
570-723-0140
    Provider Business Practice Location Address Fax Number: 
570-724-6541
    Provider Enumeration Date: 
08/03/2006