Provider First Line Business Practice Location Address: 
1650 HUNTINGDON PIKE STE 208
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MEADOWBROOK
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
19046-8006
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
215-947-6660
    Provider Business Practice Location Address Fax Number: 
215-947-1284
    Provider Enumeration Date: 
05/14/2020