Provider First Line Business Practice Location Address:
209 OLD RIVER RD
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:
18702-1615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-852-1492
Provider Business Practice Location Address Fax Number:
570-820-3288
Provider Enumeration Date:
09/15/2017