Provider First Line Business Practice Location Address:
1 W BROAD ST
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-6431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-459-0222
Provider Business Practice Location Address Fax Number:
570-459-0225
Provider Enumeration Date:
03/20/2012