Provider First Line Business Practice Location Address:
FAIRLANE VILLAGE MALL
Provider Second Line Business Practice Location Address:
7290 FAIRLANE VILLAGE MALL
Provider Business Practice Location Address City Name:
POTTSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-628-5790
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2006