Provider First Line Business Practice Location Address:
23 SCHOOL LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSABLE FORKS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12912-0835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-647-8860
Provider Business Practice Location Address Fax Number:
518-647-5749
Provider Enumeration Date:
10/13/2005