Provider First Line Business Practice Location Address:
19 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULTONVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12072-0427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-853-3999
Provider Business Practice Location Address Fax Number:
518-374-1818
Provider Enumeration Date:
08/31/2006