Provider First Line Business Practice Location Address: 
15 ASHLEY PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
QUEENSBURY
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12804-2503
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
518-798-0886
    Provider Business Practice Location Address Fax Number: 
518-743-1560
    Provider Enumeration Date: 
11/02/2005