Provider First Line Business Practice Location Address:
561 RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACKAWANNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14218-1319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-823-0141
Provider Business Practice Location Address Fax Number:
716-822-5468
Provider Enumeration Date:
09/13/2005