Approved
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Greenwood Center For Nursing And Rehab
149 Lafayette Avenue • Tamaqua, PA 18252
Personal Information
Name on Card
*
Address
Zip code
Phone Number
Email Address
*
Transaction Details
$
Amount
*
Client Name
*
Account Number
*
Facility
Credit Card Details
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Card Number
*
MMYY
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Greenwood Center For Nursing And Rehab
149 Lafayette Avenue
Tamaqua, PA 18252
Tell: 570-668-1775
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
