Provider First Line Business Practice Location Address:
764 N LOCUST ST
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:
18201-2839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-401-3780
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2013