Provider First Line Business Practice Location Address: 
601 ELMWOOD AVE
    Provider Second Line Business Practice Location Address: 
BOX MED
    Provider Business Practice Location Address City Name: 
ROCHESTER
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14642-0001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
585-275-3995
    Provider Business Practice Location Address Fax Number: 
585-442-9201
    Provider Enumeration Date: 
01/02/2008