Provider First Line Business Practice Location Address:
66 PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12932-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-873-6896
Provider Business Practice Location Address Fax Number:
518-873-6578
Provider Enumeration Date:
06/30/2005