Provider First Line Business Practice Location Address:
20 N LAUREL ST
Provider Second Line Business Practice Location Address:
SUITE 2B
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-454-5715
Provider Business Practice Location Address Fax Number:
570-455-5095
Provider Enumeration Date:
11/29/2006