Provider First Line Business Practice Location Address:
4057 STATE HIGHWAY 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAR LAKE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13690-0211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-848-3784
Provider Business Practice Location Address Fax Number:
315-848-5129
Provider Enumeration Date:
10/17/2006