Provider First Line Business Practice Location Address:
212 HIGHBRIDGE ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13066-1979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-637-9116
Provider Business Practice Location Address Fax Number:
315-637-5224
Provider Enumeration Date:
01/24/2007