Provider First Line Business Practice Location Address:
1522 STATE ROUTE 17B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE LAKE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12786-5428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-583-5620
Provider Business Practice Location Address Fax Number:
845-583-8084
Provider Enumeration Date:
08/18/2006