Provider First Line Business Practice Location Address:
1394 PLANK RD
Provider Second Line Business Practice Location Address:
BOX 302
Provider Business Practice Location Address City Name:
ELLENBURG DEPOT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-970-4774
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2014