Provider First Line Business Practice Location Address:
21087 NYS RTE 12F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601-1078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-788-8280
Provider Business Practice Location Address Fax Number:
315-785-9715
Provider Enumeration Date:
08/09/2005