Provider First Line Business Practice Location Address:
766 E BROAD ST
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:
18201-6835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-501-4987
Provider Business Practice Location Address Fax Number:
570-501-4969
Provider Enumeration Date:
12/20/2006