Provider First Line Business Practice Location Address: 
2490 SCHOENERSVILLE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALLENTOWN
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18109-9501
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
484-526-7262
    Provider Business Practice Location Address Fax Number: 
833-820-1011
    Provider Enumeration Date: 
06/20/2022