Provider First Line Business Practice Location Address: 
335 MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JOHNSON CITY
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
13790-2050
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
607-777-9801
    Provider Business Practice Location Address Fax Number: 
607-777-9807
    Provider Enumeration Date: 
12/12/2006