Provider First Line Business Practice Location Address:
212 W 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17815-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-416-1471
Provider Business Practice Location Address Fax Number:
877-251-1742
Provider Enumeration Date:
07/19/2016