Provider First Line Business Practice Location Address:
1710 E BROAD ST STE B
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:
18201-5695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-459-3002
Provider Business Practice Location Address Fax Number:
570-459-3009
Provider Enumeration Date:
07/06/2005