Provider First Line Business Practice Location Address:
919 W 15TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-454-1665
Provider Business Practice Location Address Fax Number:
570-501-2589
Provider Enumeration Date:
11/01/2006