Provider First Line Business Practice Location Address:
HC 87 BOX 109A ROUTE 940
Provider Second Line Business Practice Location Address:
VILLAGE PARK CENTER
Provider Business Practice Location Address City Name:
POCONO LAKE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-646-9444
Provider Business Practice Location Address Fax Number:
570-646-6878
Provider Enumeration Date:
12/15/2006