Provider First Line Business Practice Location Address: 
6174 LAMB RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WYOMING
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14591-9704
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
585-786-0760
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/03/2007