Provider First Line Business Practice Location Address:
776A WATERVLIET SHAKER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12110-2209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-782-2200
Provider Business Practice Location Address Fax Number:
518-786-1875
Provider Enumeration Date:
08/18/2006