Provider First Line Business Practice Location Address:
61 W BROAD ST APT 2B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NANTICOKE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18634-2261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-391-7781
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2026