Provider First Line Business Practice Location Address:
512 PRENDERGAST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14701-5322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-483-0504
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2008