Provider First Line Business Practice Location Address: 
591 MAYFLOWER XING
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WILKES BARRE
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18702-6273
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
847-291-0468
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/13/2006