Provider First Line Business Practice Location Address:
REAR 307 LAIRD 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-408-9320
Provider Business Practice Location Address Fax Number:
570-408-9324
Provider Enumeration Date:
12/24/2007