Provider First Line Business Practice Location Address:
149 N VINE ST
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:
18201-5852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-455-0923
Provider Business Practice Location Address Fax Number:
570-455-4034
Provider Enumeration Date:
06/28/2006