Provider First Line Business Practice Location Address:
305 S CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-7605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-497-4766
Provider Business Practice Location Address Fax Number:
570-245-3899
Provider Enumeration Date:
07/27/2012