Provider First Line Business Practice Location Address: 
1111 E END BLVD
    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: 
18711-0030
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
570-824-3521
    Provider Business Practice Location Address Fax Number: 
570-819-5133
    Provider Enumeration Date: 
07/25/2006