Provider First Line Business Practice Location Address:
1423 BUTTERNUT 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:
13208-2372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-373-0187
Provider Business Practice Location Address Fax Number:
315-396-0310
Provider Enumeration Date:
06/16/2005