Provider First Line Business Practice Location Address: 
45 ASHLEY AVE
    Provider Second Line Business Practice Location Address: 
ACT TEAM
    Provider Business Practice Location Address City Name: 
MIDDLETOWN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10940-1912
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-326-8073
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/19/2009