Provider First Line Business Practice Location Address: 
3680 HILL BLVD
    Provider Second Line Business Practice Location Address: 
CAREMOUNT MEDICAL PC
    Provider Business Practice Location Address City Name: 
JEFFERSON VALLEY
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10535-1500
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
914-241-1050
    Provider Business Practice Location Address Fax Number: 
914-248-2081
    Provider Enumeration Date: 
01/22/2007