Provider First Line Business Practice Location Address:
18 COYOTE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-523-7840
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/24/2006