Provider First Line Business Practice Location Address:
218 N COMRIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12095-1506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-762-1676
Provider Business Practice Location Address Fax Number:
518-762-3139
Provider Enumeration Date:
11/19/2007