Provider First Line Business Practice Location Address:
166 HANOVER ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
WILKES BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18702-3549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-822-5191
Provider Business Practice Location Address Fax Number:
570-822-2450
Provider Enumeration Date:
07/22/2005