Provider First Line Business Practice Location Address: 
1266 LIBERTY ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FRANKLIN
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
16323-1322
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
814-437-5776
    Provider Business Practice Location Address Fax Number: 
814-437-5304
    Provider Enumeration Date: 
09/06/2011