Provider First Line Business Practice Location Address:
2105 W GENESEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13219-1656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-488-6638
Provider Business Practice Location Address Fax Number:
315-487-2815
Provider Enumeration Date:
11/15/2005