Provider First Line Business Practice Location Address: 
941 SOUTH AVE
    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: 
14620-2746
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
585-473-2858
    Provider Business Practice Location Address Fax Number: 
585-461-3771
    Provider Enumeration Date: 
11/10/2013