Provider First Line Business Practice Location Address:
642 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
APT 3
Provider Business Practice Location Address City Name:
OLD FORGE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18518-1784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-702-7404
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2007