Provider First Line Business Practice Location Address:
601 S POPLAR ST STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-7707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-535-8780
Provider Business Practice Location Address Fax Number:
570-535-8274
Provider Enumeration Date:
09/26/2025