Provider First Line Business Practice Location Address:
675 BALTIMORE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILKES BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18702-7900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-808-5626
Provider Business Practice Location Address Fax Number:
570-808-6352
Provider Enumeration Date:
06/23/2011