Provider First Line Business Practice Location Address:
1000 E MOUNTAIN DR
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:
18711-0027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-808-7754
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2018