Provider First Line Business Practice Location Address:
136 E 12TH 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:
17815-3808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-774-9582
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2016