Provider First Line Business Practice Location Address:
388 MILL POND DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-523-9512
Provider Business Practice Location Address Fax Number:
518-523-5379
Provider Enumeration Date:
10/26/2005