Provider First Line Business Practice Location Address:
452 HAZLE ST
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:
18702-4627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-823-3818
Provider Business Practice Location Address Fax Number:
570-825-6189
Provider Enumeration Date:
06/20/2005