Provider First Line Business Practice Location Address:
254 BROOKLYN ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18407-1879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-282-3347
Provider Business Practice Location Address Fax Number:
570-282-2189
Provider Enumeration Date:
05/24/2005