Provider First Line Business Practice Location Address:
25 LAUREL MALL
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:
18202-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-455-7704
Provider Business Practice Location Address Fax Number:
570-455-7704
Provider Enumeration Date:
11/26/2007