Provider First Line Business Practice Location Address:
1123 RT 146A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALLSTON LAKE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-399-7066
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2005