Provider First Line Business Practice Location Address: 
120 WASHINGTON AVENUE EXT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALBANY
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12203-5367
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
518-456-4151
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/30/2008