Provider First Line Business Practice Location Address: 
159 WEST FIRST STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OSWEGO
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
13126
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
315-342-9575
    Provider Business Practice Location Address Fax Number: 
315-342-7664
    Provider Enumeration Date: 
08/12/2014