Provider First Line Business Practice Location Address:
100 N PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILKES BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18701-3507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-296-5262
Provider Business Practice Location Address Fax Number:
877-991-8819
Provider Enumeration Date:
06/19/2025