Provider First Line Business Practice Location Address:
NEWCOMB ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG LAKE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12487-0415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-624-6661
Provider Business Practice Location Address Fax Number:
518-624-6319
Provider Enumeration Date:
10/26/2005