Provider First Line Business Practice Location Address:
410 GLEN AVENUE
Provider Second Line Business Practice Location Address:
MEDICAL PROFESSIONAL BUILDING, SUIITE 101
Provider Business Practice Location Address City Name:
BLOOMSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-387-2135
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2006