Provider First Line Business Practice Location Address:
104 W WATER ST
Provider Second Line Business Practice Location Address:
APARTMENT 3
Provider Business Practice Location Address City Name:
LOCK HAVEN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17745-1296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-752-1637
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2012