Provider First Line Business Practice Location Address:
104 LAFAYETTE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13205-2907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-492-0248
Provider Business Practice Location Address Fax Number:
315-492-0250
Provider Enumeration Date:
10/10/2011