Provider First Line Business Practice Location Address:
801 E BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMAQUA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18252-2210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-952-8219
Provider Business Practice Location Address Fax Number:
570-952-8119
Provider Enumeration Date:
05/24/2005