Provider First Line Business Practice Location Address: 
152 BAY ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GLENS FALLS
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12801-2329
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
518-792-4140
    Provider Business Practice Location Address Fax Number: 
518-792-9008
    Provider Enumeration Date: 
11/30/2006