Provider First Line Business Practice Location Address: 
220 CLAREMONT AVE
    Provider Second Line Business Practice Location Address: 
SUITE #2
    Provider Business Practice Location Address City Name: 
TAMAQUA
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18252-4460
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
570-668-1900
    Provider Business Practice Location Address Fax Number: 
570-668-8812
    Provider Enumeration Date: 
02/28/2011