Provider First Line Business Practice Location Address:
28 WILKESBARRE ST APT 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACKAWANNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14218-1125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-352-7566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/12/2020