Provider First Line Business Practice Location Address:
1177 COUNTY ROUTE 23
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12832-2718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-642-2708
Provider Business Practice Location Address Fax Number:
518-642-3988
Provider Enumeration Date:
08/10/2006