Provider First Line Business Practice Location Address:
227 RIDGE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACKAWANNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-822-5944
Provider Business Practice Location Address Fax Number:
716-822-3937
Provider Enumeration Date:
12/01/2008