Provider First Line Business Practice Location Address:
29 CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12946-1805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-897-2317
Provider Business Practice Location Address Fax Number:
518-897-2423
Provider Enumeration Date:
01/19/2007