Provider First Line Business Practice Location Address: 
6228 ROUTE 82
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
STANFORDVILLE
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12581-5803
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-392-4900
    Provider Business Practice Location Address Fax Number: 
845-868-1163
    Provider Enumeration Date: 
06/10/2009