Provider First Line Business Practice Location Address:
20 PROSPECT ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
BALLSTON SPA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12020-1367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-885-3755
Provider Business Practice Location Address Fax Number:
518-885-4613
Provider Enumeration Date:
08/10/2005