Provider First Line Business Practice Location Address:
169 NORTH GRANT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAMOKIN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-492-0312
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2011