Provider First Line Business Practice Location Address: 
475 MORGAN HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SCRANTON
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18508-2605
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
570-341-4317
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/29/2005