Provider First Line Business Practice Location Address:
2600 SOUTHPARK AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACKAWANNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14218-1504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-822-2028
Provider Business Practice Location Address Fax Number:
716-822-2029
Provider Enumeration Date:
04/09/2008