Provider First Line Business Practice Location Address:
565 N LAUREL ST APT 1N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-5180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-209-9981
Provider Business Practice Location Address Fax Number:
484-214-0088
Provider Enumeration Date:
08/14/2024