Provider First Line Business Practice Location Address: 
1585 MILITARY TURNPIKE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PLATTSBURGH
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12901
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
518-561-0100
    Provider Business Practice Location Address Fax Number: 
518-561-2390
    Provider Enumeration Date: 
07/07/2011