Provider First Line Business Practice Location Address:
220 CHURCH AVE
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
BALLSTON SPA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12020-3613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-248-2478
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2010