C03965;TA112952;TCO3;1;1027316-JS;JAMES SMITH-654;WILKES-BARRE GWV;1155 EAST MTN. BLVD, ENTRANCE "A" PODIATRY;WILKES BARRE;PA;18711;07/01/25
C03965;TA112952;20011M105;1;1027316-JS;JAMES SMITH-654;WILKES-BARRE GWV;1155 EAST MTN. BLVD, ENTRANCE "A" PODIATRY;WILKES BARRE;PA;18711;07/01/25
C03965;TA112952;COMP;No
