Provider First Line Business Practice Location Address: 
1503 N. CEDAR CREST BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALLENTOWN
    Provider Business Practice Location Address State Name: 
PA
    Provider Business Practice Location Address Postal Code: 
18104-2301
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
610-861-8080
    Provider Business Practice Location Address Fax Number: 
610-807-0366
    Provider Enumeration Date: 
08/30/2006