Provider First Line Business Practice Location Address: 
2 ELM ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MC GRAW
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
13101-9471
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
607-836-7540
    Provider Business Practice Location Address Fax Number: 
607-836-4180
    Provider Enumeration Date: 
05/26/2006