Provider First Line Business Practice Location Address: 
300 WYOMING AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WYOMING
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18644-1695
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
570-693-2900
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/23/2014