Provider First Line Business Practice Location Address: 
42 1/2 ELM ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
POTSDAM
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
13676-1813
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
315-261-9210
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/19/2022