Provider First Line Business Practice Location Address:
16 AUTUMN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12946-3634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-523-5882
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/06/2008