Provider First Line Business Practice Location Address: 
1 LOOP RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AUBURN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
13021-3635
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
315-255-1156
    Provider Business Practice Location Address Fax Number: 
315-255-0847
    Provider Enumeration Date: 
09/08/2009