Provider First Line Business Practice Location Address:
54 MELROY AVE
Provider Second Line Business Practice Location Address:
APT 2
Provider Business Practice Location Address City Name:
LACKAWANNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14218-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-253-9283
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2011