Provider First Line Business Practice Location Address:
7569 ROUTE 54
Provider Second Line Business Practice Location Address:
LAKEVIEW MEDICAL ARTS BUILDING
Provider Business Practice Location Address City Name:
BATH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14810-9533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-776-9195
Provider Business Practice Location Address Fax Number:
607-776-4272
Provider Enumeration Date:
12/23/2009