Provider First Line Business Practice Location Address: 
4 AIRPORT PARK BLVD
    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: 
12110-6416
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
518-782-7770
    Provider Business Practice Location Address Fax Number: 
518-782-0047
    Provider Enumeration Date: 
06/19/2006