Provider First Line Business Practice Location Address:
53 GRAVEL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILKES BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18705-3738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-789-0845
Provider Business Practice Location Address Fax Number:
570-371-5604
Provider Enumeration Date:
06/29/2009