Provider First Line Business Practice Location Address:
501 STATE RTE 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW LEBANON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-794-7216
Provider Business Practice Location Address Fax Number:
518-794-0180
Provider Enumeration Date:
09/20/2005