Provider First Line Business Practice Location Address:
1740 E BROAD 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:
18201-5667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-459-2902
Provider Business Practice Location Address Fax Number:
570-459-6090
Provider Enumeration Date:
08/23/2005