Provider First Line Business Practice Location Address:
410 GLENN AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
BLOOMSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17815-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-387-2202
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2005