Provider First Line Business Practice Location Address:
1086 PA-315
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:
18419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-823-7761
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2025