Provider First Line Business Practice Location Address:
RR#3 BOX 3053
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARVEY'S LAKE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18618-9789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-674-3998
Provider Business Practice Location Address Fax Number:
570-639-5260
Provider Enumeration Date:
10/22/2008