Provider First Line Business Practice Location Address: 
242 MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ONEONTA
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
13820-2527
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
607-431-1030
    Provider Business Practice Location Address Fax Number: 
607-431-1033
    Provider Enumeration Date: 
10/17/2011