Provider First Line Business Practice Location Address: 
69 MOUNTAIN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HIGHLAND FALLS
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10928-1316
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
904-540-4242
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/08/2011