Provider First Line Business Practice Location Address:
330 LAUREL MALL
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18202-1205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-223-7777
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2006