Provider First Line Business Practice Location Address:
141 N VINE 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:
18201-5852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-501-6322
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2011