Provider First Line Business Practice Location Address:
34 W ROSS ST APT 1
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:
18701-1552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-993-1865
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2022