Provider First Line Business Practice Location Address:
29 REED AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACKAWANNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14218-1618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-274-5740
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/22/2011