Provider First Line Business Practice Location Address: 
3268 EASTON AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BETHLEHEM
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18020-3451
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
610-871-2960
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/01/2006