Provider First Line Business Practice Location Address:
190 WELLES ST
Provider Second Line Business Practice Location Address:
SUITE 166
Provider Business Practice Location Address City Name:
FORTY FORT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18704-4968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-714-4177
Provider Business Practice Location Address Fax Number:
570-714-4188
Provider Enumeration Date:
06/12/2006