Provider First Line Business Practice Location Address:
1003 STATE ROUTE 80
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-837-4407
Provider Business Practice Location Address Fax Number:
315-837-4775
Provider Enumeration Date:
01/30/2012