Provider First Line Business Practice Location Address: 
915 HICKORY ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOLLIDAYSBURG
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
16648-2247
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-696-4503
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/03/2011