Provider First Line Business Practice Location Address:
1 HIGH PATH
Provider Second Line Business Practice Location Address:
HOPE HOUSE
Provider Business Practice Location Address City Name:
PORT JEFFERSON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11777-1276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-928-9112
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2005