Provider First Line Business Practice Location Address:
3071 3085 SOUTH PARK AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACKAWANNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14218-3107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-824-6263
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006