Provider First Line Business Practice Location Address:
2554 RTE 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALLSTON SPA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-899-5002
Provider Business Practice Location Address Fax Number:
518-899-5603
Provider Enumeration Date:
11/22/2006