Provider First Line Business Practice Location Address: 
1020 TOWNE SQUARE DR
    Provider Second Line Business Practice Location Address: 
SUITE 1020-4
    Provider Business Practice Location Address City Name: 
GREENSBURG
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
15601-5959
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
724-863-5503
    Provider Business Practice Location Address Fax Number: 
724-863-5620
    Provider Enumeration Date: 
05/02/2006