Provider First Line Business Practice Location Address:
RR1 ROUTE 611
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TANNERSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-236-8944
Provider Business Practice Location Address Fax Number:
570-629-8408
Provider Enumeration Date:
12/29/2006