Provider First Line Business Practice Location Address: 
14 CENTER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CUBA
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14727-1002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
585-968-3210
    Provider Business Practice Location Address Fax Number: 
585-968-3031
    Provider Enumeration Date: 
09/25/2009