Provider First Line Business Practice Location Address:
111 SULLIVAN AVE
Provider Second Line Business Practice Location Address:
LIBERTY MEDICAL GROUP
Provider Business Practice Location Address City Name:
FERNDALE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12734-4315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-292-6630
Provider Business Practice Location Address Fax Number:
845-292-8460
Provider Enumeration Date:
12/30/2005