Provider First Line Business Practice Location Address:
12 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACEYVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-282-5652
Provider Business Practice Location Address Fax Number:
570-282-5653
Provider Enumeration Date:
08/24/2007