Provider First Line Business Practice Location Address:
25 CHURCH 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:
18702-3507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-507-4957
Provider Business Practice Location Address Fax Number:
866-810-6910
Provider Enumeration Date:
11/06/2013