Provider First Line Business Practice Location Address:
123 COLUMBIA DR
Provider Second Line Business Practice Location Address:
STE B JAY PARK
Provider Business Practice Location Address City Name:
MARSHALLS CREEK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18335-0194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-223-4191
Provider Business Practice Location Address Fax Number:
570-223-2745
Provider Enumeration Date:
09/15/2006