Provider First Line Business Practice Location Address: 
2937 ROUTE 611 UNIT 14
    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: 
18372-6000
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
570-426-1413
    Provider Business Practice Location Address Fax Number: 
570-426-1737
    Provider Enumeration Date: 
10/24/2006