Provider First Line Business Practice Location Address:
69 JOHNSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-857-0144
Provider Business Practice Location Address Fax Number:
518-786-8172
Provider Enumeration Date:
11/04/2008