Provider First Line Business Practice Location Address: 
857 COUNTY ROUTE 164
    Provider Second Line Business Practice Location Address: 
APT. B
    Provider Business Practice Location Address City Name: 
CALLICOON
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12723-5639
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-887-4114
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/18/2010