Provider First Line Business Practice Location Address: 
475 IRVING AVE
    Provider Second Line Business Practice Location Address: 
STE. 300
    Provider Business Practice Location Address City Name: 
SYRACUSE
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
13210-1756
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
315-464-7010
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/18/2010