Provider First Line Business Practice Location Address: 
9300 LAKE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BROCTON
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14716-9621
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
716-792-7100
    Provider Business Practice Location Address Fax Number: 
716-792-7115
    Provider Enumeration Date: 
09/25/2011