Provider First Line Business Practice Location Address:
112 DEWITT ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13203-2890
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-415-4880
Provider Business Practice Location Address Fax Number:
315-469-4474
Provider Enumeration Date:
01/14/2007