Provider First Line Business Practice Location Address:
415 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACEYVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-869-8700
Provider Business Practice Location Address Fax Number:
570-869-8714
Provider Enumeration Date:
10/25/2006