Provider First Line Business Practice Location Address:
SCDHS 3500 SUNRISE HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 124
Provider Business Practice Location Address City Name:
GREAT RIVER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11739-9006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-854-0206
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2006