Provider First Line Business Practice Location Address:
736 IRVING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13210-1687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-470-7828
Provider Business Practice Location Address Fax Number:
315-470-5811
Provider Enumeration Date:
06/22/2005