Provider First Line Business Practice Location Address: 
14 SCOTCHTOWN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GOSHEN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10924-1631
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-294-3312
    Provider Business Practice Location Address Fax Number: 
845-294-3371
    Provider Enumeration Date: 
09/01/2009