Provider First Line Business Practice Location Address:
1131 ROUTE 55
Provider Second Line Business Practice Location Address:
STE 1D
Provider Business Practice Location Address City Name:
LAGRANGEVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12540-5063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-913-5513
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2011