Provider First Line Business Practice Location Address:
792 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 100B
Provider Business Practice Location Address City Name:
N SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13212-1644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-458-4623
Provider Business Practice Location Address Fax Number:
315-458-4652
Provider Enumeration Date:
09/29/2005