Provider First Line Business Practice Location Address:
219 S BALLIET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRACKVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17931-2105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-874-1491
Provider Business Practice Location Address Fax Number:
570-874-3404
Provider Enumeration Date:
07/13/2007