Provider First Line Business Practice Location Address:
276 RECREATION BLDG BLDG
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PARK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16802-5701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-863-0442
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2018