Provider First Line Business Practice Location Address:
1201 N CHURCH ST
Provider Second Line Business Practice Location Address:
STE 209
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18202-1455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-459-6245
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2005