Provider First Line Business Practice Location Address:
495 LAKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANADENSIS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18325-7842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-595-6055
Provider Business Practice Location Address Fax Number:
570-595-6055
Provider Enumeration Date:
12/29/2009