Provider First Line Business Practice Location Address:
RR 1 BOX 400
Provider Second Line Business Practice Location Address:
TANNERSVILLE PLAZA
Provider Business Practice Location Address City Name:
TANNERSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18372-9037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-619-5413
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2010