Provider First Line Business Practice Location Address:
1110 ROUTE 55
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
LAGRANGEVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12540-5045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-615-9146
Provider Business Practice Location Address Fax Number:
585-334-0208
Provider Enumeration Date:
04/02/2008