Provider First Line Business Practice Location Address:
6356 NYS ROUTE 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIAN LAKE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12842-2021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-648-5707
Provider Business Practice Location Address Fax Number:
518-648-6160
Provider Enumeration Date:
08/31/2006