Provider First Line Business Practice Location Address:
201 PROSPECT AVE
Provider Second Line Business Practice Location Address:
CPEP
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13203-1805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-448-6555
Provider Business Practice Location Address Fax Number:
315-423-6820
Provider Enumeration Date:
08/09/2006