Provider First Line Business Practice Location Address: 
2577 SHERIDAN DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TONAWANDA
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14150-9411
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
716-874-2040
    Provider Business Practice Location Address Fax Number: 
716-832-0124
    Provider Enumeration Date: 
04/27/2006