Provider First Line Business Practice Location Address:
470 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDWARDSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18704-3275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-288-8464
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2006