Provider First Line Business Practice Location Address:
1227 LIBERTY STREET
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
ALLENTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
123-456-7890
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/18/2006