Provider First Line Business Practice Location Address: 
5 MAIN ST
    Provider Second Line Business Practice Location Address: 
SUITE 6
    Provider Business Practice Location Address City Name: 
QUEENSBURY
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12804
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
518-798-2225
    Provider Business Practice Location Address Fax Number: 
518-798-2807
    Provider Enumeration Date: 
10/31/2006