Provider First Line Business Practice Location Address: 
99 SLINGERLAND ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALBANY
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12202-1223
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
518-463-2247
    Provider Business Practice Location Address Fax Number: 
518-463-9880
    Provider Enumeration Date: 
09/26/2011