Provider First Line Business Practice Location Address: 
190 WASHINGTON AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BATAVIA
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14020-2113
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
585-344-1227
    Provider Business Practice Location Address Fax Number: 
585-345-9012
    Provider Enumeration Date: 
12/30/2005