Provider First Line Business Practice Location Address:
564 W BROAD ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-6108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-501-6220
Provider Business Practice Location Address Fax Number:
570-501-2795
Provider Enumeration Date:
08/20/2014