Provider First Line Business Practice Location Address: 
1425 PORTLAND AVE # 306
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ROCHESTER
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14621-3001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
585-441-5320
    Provider Business Practice Location Address Fax Number: 
585-922-9359
    Provider Enumeration Date: 
08/06/2014