Provider First Line Business Practice Location Address:
145 CLINTON ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601-3621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-788-1190
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2007