Provider First Line Business Practice Location Address:
744 KIDDER 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:
18702-7015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-829-3477
Provider Business Practice Location Address Fax Number:
570-829-7918
Provider Enumeration Date:
11/21/2016