Provider First Line Business Practice Location Address:
583 HARRISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-4663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-450-5688
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2012