Provider First Line Business Practice Location Address: 
25 ULSTER AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAUGERTIES
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12477-1212
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-246-3642
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/06/2015