Provider First Line Business Practice Location Address:
2369 ROUTE 715
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TANNERSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-629-9507
Provider Business Practice Location Address Fax Number:
272-200-2977
Provider Enumeration Date:
04/21/2006