Provider First Line Business Practice Location Address:
316 GOSHEN AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-0603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-436-1635
Provider Business Practice Location Address Fax Number:
570-434-1635
Provider Enumeration Date:
01/12/2006