Provider First Line Business Practice Location Address:
101 S CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-6279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-501-2692
Provider Business Practice Location Address Fax Number:
570-501-2695
Provider Enumeration Date:
07/06/2006